The Foot and Ankle Tribune

New Years Resolutions

2012-01-11T05:39:00.001-08:00

Every year around mid January and into February, we get an influx of patients who are very driven to lose weight secondary to overindulgent eating during the holiday season. This leads to a high degree of previously inactive individuals who are developing heel pain from their newly achieved activity level. This creates a formidable foe with regards to maintaining an exercise level consistant with weight loss goals.

At FFLC we strive to get you back out there running, and this is done via a variety of measures for treatment of heel pain, which consists of well conforming inserts for your shoes, as well as ultrasound guided examinations to pinpoint pathology and isolate sore bursal formations and fascia tears. We strive to keep this community active, and usually this can be managed without surgical interventions. We routinely perform physician guided physical therapy at out PT office and for difficult to resolve pain, we will utilize state of the art extracorporal shock wave therapy.

When you are not stretching your legs and heels appropriately, a night splint may be very useful to allow you to stretch out the fascia and reduce recurrence of painful heels. With xrays on site and experienced foot and ankle surgeons on your side, it is no wonder Naples continues to stay active, even when heel pain becomes part of the equation.

Mucoid Cysts in the Toes

2011-12-15T07:13:00.000-08:00

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

2011-11-15T06:46:00.001-08:00

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?

2011-11-01T11:18:00.000-07:00

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

2011-10-26T11:18:00.000-07:00

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

2011-10-12T05:03:00.000-07:00

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

2011-10-03T11:05:00.000-07:00

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

2011-09-13T10:25:00.000-07:00

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 ?

2011-08-25T06:52:00.000-07:00

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" :

2011-08-08T07:16:00.001-07:00

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

2011-08-04T11:07:00.000-07:00

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

2011-07-28T06:29:00.000-07:00

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'??

2011-07-18T06:39:00.000-07:00

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"

2011-06-27T10:16:00.001-07:00

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!

2011-06-08T10:32:00.000-07:00

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

2011-05-10T05:47:00.001-07:00

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

2011-04-21T05:46:00.001-07:00

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

2011-03-17T07:21:00.001-07:00

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!

2011-02-01T07:36:00.000-08:00

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.

Z - Coil Is HERE!!

2010-08-27T06:44:00.000-07:00

Family Foot and Leg Center is the only registered distributer of this fine product in Naples Florida.

Here are some commonly asked questions and answers for our patients convenience.

What types of painful conditions may be alleviated by wearing Z-CoiL® footwear?

Z-CoiL®-wearers have reported significant relief from the pain associated with many medically-diagnosed conditions, including:
• Heel spurs, plantar fasciitis, and metatarsal pain
• Lower back pain and sciatica
• Arthritis and other common joint pains

Will Z-CoiL® footwear help me jump higher?
No, but you will land softer.

How soon before I can expect results?
The relief our customers experience may be immediate, or may occur gradually, over days or even weeks. Some people enjoy complete relief from pain when wearing their Z-CoiL® shoes; others achieve only partial relief, though they may be able to reduce the amount of pain medication they take.

Is Z-CoiL® footwear stable?
Many customers report that they actually feel more stable in their Z-CoiL® footwear than in regular shoes. The coil in the heel is cone-shaped, and so it compresses straight down, following the line of least resistance rather than tipping. The flexible coil also absorbs some surface deviations to protect the ankle.

Does it take a long time to get used to wearing Z-CoiL® footwear?
Most people get used to wearing the footwear right away. Others may take several hours or even a couple of days to adjust to the extraordinary feeling of the shoes. If this is the case, we suggest you wear your Z-CoiL® shoes for a few hours each day at first, and gradually increase that time until you feel more comfortable in them.

It is also normal to experience some soreness in your legs during the first few weeks of wearing Z-CoiL® shoes, due to the increased mobility they provide. If you continue to experience pain in your feet, ankles, knees, hips, or back while wearing your Z-CoiL® footwear, however, you should take them off and return to your
Z-CoiL® distributor for a footwear adjustment.

Can objects get caught in the open coil?
Small rocks or loose materials may occasionally get caught in the coil, but they should be easy to remove with a simple shake. We do recommend caution around cords, wires, hoses, and chairs with rungs, which may catch in the coil.

Can I drive wearing Z-CoiL® footwear?
Yes, but be careful not to let the floor mat or pedals catch on the coil. Also be aware that the shoes thick cushioning may reduce your feel for the pedals. You may need to move your seat back an inch or so to compensate for the thickness of the forefoot cushioning. If you feel unsafe driving in your Z-CoiL® footwear, wear other shoes.

Can I use my Z-CoiL® footwear to play sports?
Our customers have reported using their Z-CoiL® shoes for walking, running, hiking, golf, and more, although we do not recommend them for sports that involve significant lateral movement, like tennis. You need to be the judge of how Z-CoiL® products will work for you. Many people have been able to become more active and get back in the game because of their Z-CoiL® footwear.

Can I use custom orthotics with them?
You certainly can. In fact, Z-CoiL® footwear makes an ideal footbed for custom orthotics. Skilled Z-CoiL® fitters will ensure that your prescription orthoses fit in your shoes properly. Your prescribing healthcare professional may even be able to work with the Z-CoiL® fitter to further enhance the performance of your orthotics.

Arent Z-CoiL® shoes considered high heels?
Not at all. The Z-CoiL® heel, when uncompressed, is only about 1/2 of an inch higher than the cushioned forefoot. When the coil compresses, an average distance of 1/8 to 1/4 of an inch, the heel is level or just slightly higher than the forefoot. This minimal heel rise is beneficial to most people, helping them achieve a healthier, more erect standing posture. In the rare event that this is not the case, the coils can be adjusted to a lower effective heel height.

How long will my Z-CoiL® shoes last?
The steel coils can last a lifetime, though the rubber heel pad will probably last between six months and two years with normal use. People who put their Z-CoiL® footwear to hard use may wear through the pad in three months, while those who go easy on their footwear have been known to wear them for several years. Fortunately, even if the heel pad does wear out, there’s no need to buy a new pair of shoes. The coil/heel pad assembly can easily be replaced by a Z-CoiL® distributor at a minimal cost.

By comparison, most running or comfort shoes with EVA or gel-based soles have a life of 200 miles or 3 months, at which time their cushioning is reduced by 50%.

Some of your shoes have optional foam heel covers; why don’t you cover up the coils on all your styles?
We do make an Enclosed Heel System™(ECS) that comes standard with our Z-Duty Work Boot and Z-Walker Safety Toe styles, and can also be retrofitted on our other styles. The ECS is designed to address workplace safety concerns, in environments where objects are more likely to get caught in an open coil. The molded foam material that encases the coil slows the speed at which the coil compresses, which dampens its shock-absorbing capabilities to some degree, although a stiffer coil also proves useful when a person is picking up heavy objects.

At first, many people are taken aback by the appearance of our shoes; however, those who put them on and experience significant relief from pain soon see them in a different light!

Can I order Z-CoiL® footwear over the Internet or by phone? There is no Z-CoiL® store near me.
Yes you can! In August 2010, Z-CoiL changed its long-standing policy of no internet or phone sales in response to strong customer demand. We still believe that a personalized fit is essential for maximizing the incredible pain relief benefits of Z-Coil shoes. However, for those people in pain who have difficulty visiting a store near them, we now offer Online andTelephone Sales. We ask the customer a series of fitting questions and make corresponding adjustments to the shoes prior to shipping. If further adjustments are needed, we encourage the customer to visit their nearest Z-CoiL distributor. We also offer a Risk-Free, 30-Day Trial Period.

Where are Z-CoiL® shoes manufactured?
Z-CoiL Footwear is headquartered in Albuquerque, New Mexico, where the products are designed and engineered. Our products are manufactured in South Korea. Al Gallegos had tried for years to find a U.S. shoe manufacturer willing to produce his unusual shoes, but they all laughed at his idea and turned him down. At last he found a willing partner in South Korea who had 20 years of experience, including making products for Nike® and Reebok®.

Hopefully this is helpful for you all, and please do not hesitate to ask us about our shoes, as the doctors here at FFLC will be sporting these new shoes at the Downtown and East Naples locations.

Dr Timm

OLT (Osteochondral lesions of the talus)

2010-08-09T06:40:00.000-07:00

O.L.T. (Otherwise known as OCD of the talus)

This is a relatively common pathology that is seen at the Family Foot and Leg Center. We are not referring to an obsessive compulsive disorder of the foot, we are referring to cartilage damage within the ankle joint.

Pathology

Anterolateral lesions on the talar dome result from inversion and dorsiflexion forces, which cause the anterolateral aspect of the talar dome to impact the fibula. These lesions are usually shallower and more wafer-shaped than medial lesions, possibly because of a more tangential force vector that results in shearing-type forces.
Posttraumatic medial lesions are deeper and cup-shaped. They result from a combination of inversion, plantarflexion, and external rotation forces that cause the posteromedial talar dome to impact the tibial articular surface with a relatively more perpendicular force vector.
A study of the contact pressures on the talus with varying degrees of lateral ligament transections and ankle positions showed that the medial rim of the talus was subjected to high pressures, even without ligamentous transection. Results of another study implicated the difference in cartilage stiffness; the tibial cartilage is 18-37% stiffer than the corresponding sites on the talus.

The results of other studies indicated that the mean cartilage thickness is inversely related to the mean compressive modulus. These findings may lend credence to the clinically observed etiology of osteochondral lesions of the talus (OLTs) (ie, repetitive overuse syndrome in medial lesions and an acute traumatic event in lateral lesions).
Observations from biomechanical studies suggest that the size of the lesion may alter the contact stresses in the ankle. Statistically significant changes in contact characteristics occur with lesions larger than 7.5 mm × 15 mm; this finding indicates that lesion size may play a role in predicting long-term outcome.

Presentation

In most cases, the mechanism of injury is an inversion injury to the lateral ligamentous complex. Patients typically present with chronic ankle pain along with intermittent swelling and, possibly, weakness, stiffness, instability, and giving way.
Upon physical examination, assess joint laxity with the anterior drawer test and assess strength by comparison with the contralateral ankle. Physical examination findings of joint laxity are uncommon. Palpation may reveal tenderness behind the medial malleolus when the ankle is dorsiflexed, indicating a posteromedial lesion. Anterolateral lesions may be tender when the anterolateral ankle joint is palpated with the joint in maximal plantarflexion.

Treatment
Medical Therapy
Conservative management of osteochondral lesions of the talus (OLTs) should be attempted first. Symptomatic patients with negative findings on plain radiographs should undergo an initial period of immobilization, followed by physical therapy. Studies have shown that a trial of conservative therapy does not adversely affect surgery performed after conservative therapy has failed. Patients whose plain images indicate OLTs and those who remain symptomatic after 6 weeks should undergo additional evaluation with MRI.

Surgical Therapy
Surgical treatment depends on a variety of factors, including patient characteristics (eg, activity level, age, degenerative changes) and lesions (eg, location, size, chronicity). However, surgical treatment adheres to 1 of the following 3 principles:
1) Loose-body removal with or without stimulation of fibrocartilage growth (microfracture, curettage, abrasion, or transarticular drilling)
2) Securing OLTs to the talar dome through retrograde drilling, bone grafting, or internal fixation
3) Stimulating the development of hyaline cartilage through osteochondral autografts (osteochondral autograft transfer system [OATS], mosaicplasty), allografts, or cell culture (Carticel, Genzyme Biosurgery, Cambridge, Mass)

Arthroscopic intervention is associated with less surgical morbidity and joint stiffness, decreased rehabilitation time, and an increased functional outcome.

Postoperative Details
A postoperative rehabilitation program should be tailored to each patient's individual circumstances and goals by a licensed physical therapist. Rehabilitation can generally begin after healing is demonstrated, which may occur after 6-7 weeks of non–weightbearing status if drilling or internal fixation was performed. With the goal of attaining full ankle range of motion, physical rehabilitation includes active and passive range-of-motion exercises and a home program, edema control, and strength and proprioceptive training.

Follow-up

Pain following operative treatment of OLTs is common for up to a year. MRI changes, including edema, are slow to resolve and often match the patient's report of an achy feeling in the joint. After 6 months, a persistent effusion, a catching sensation, or severe pain signifies that healing is not progressing as intended, and further investigation with CT or MRI is appropriate.
For excellent patient education resources, visit eMedicine's Foot, Ankle, Knee, and Hip Center and Imaging Center. Also, see eMedicine's patient education articles Ankle Arthroscopy, Understanding X-rays, and Magnetic Resonance Imaging (MRI).

Bone infections of the foot and ankle

2010-07-21T10:22:00.000-07:00

Osteomyelitis or bone infections

This is a relatively common pathology that we see at the Family Foot and Leg Center here in Naples, Florida. Many patients will end up with this devastating diagnosis and it will lead to a number of amputations across the country, with each year steadily increasing the number of foot and leg amputations primarily from patients with diabetes and the associated complications from such especially with neuropathy and vascular disease.

We try to utilize the most innovative technology to try and prevent this devastating complication (ie amputations) , with the use of state of the art external fixators, MicroVas microcirculatory therapy, wound care referrals, and closely working with infectious disease doctors for management of the systemic portion of treatment especially in the case of ankle osteomyelitis. This usually includes intravenous antibiotics and weekly monitoring of blood tests. Sometimes it includes partial amputations of toes, feet, or even the leg.

We pride ourselves on diabetic limb salvage, which essentially includes treatment of bone infections of the ankle and foot, as well as prevention of these problems. We also utilize specific rotation flaps for wound coverage and insertion of antibiotic bone spacers within the area of concern to aide in bone removal and replacement, to prevent major amputations and loss of legs. Most ulcerations of our diabetic patients that have been present for 3 months or more may lead to underlying bone infections in weight bearing areas of the foot if not adequately treated, and a qualified wound care specialist (of our practice we have 3 physicians for this) is essential for optimal outcomes.

We also provide excellent prophylactic treatment and maintenence of our diabetic patients with routine foot examinations and vascular studies to rule out limb threatening vascular disease, with proper referrals as needed. We pride ourselves on our abilities to not only treat, erradicate infection, and save legs and feet. But we also provide excellent maintenence therapies to our patients to prevent these outcomes entirely. We are part of a team of physicians, nurses, and health care practitioners who are entirely dedicated to our diabetic patients to maintain daily activities, walking, and prevention of serious complications stemming from the pathology of diabetes.

Any comments are welcome, as I am willing to respond to questions, comments, or concerns at any time.

Overview of Peroneal Tendon Issues

2010-05-27T06:13:00.000-07:00

Clincal picture of dislocating peroneals in ankle neutral.

Many patients that we treat at our office have chronic ankle instability in the form of lateral tendon dislcocations, or chronic ankle sprains. Many times these patients are unclear as to how important these tendons are to the overal stability and function of the ankle joint. With abnormal tendon gliding and ligamentous attenuations and ruptures, these tendons may also become painful with patients who have chronic ankle sprains. This is a comprehensive overview of this pathology and treatment options to help out with the understanding of these clinical scenarios.

History of the Procedure
Disorders of the peroneal tendons have been reported infrequently. Monteggia described peroneal tendon subluxation in 1803, and this entity seems to be more commonly encountered than are disruptions of the peroneus longus or brevis alone. Nonetheless, peroneus brevis disorders have been described more often in the literature, with peroneus longus problems gaining more recent attention. However, much of the literature regarding both tendons is in the form of case reports.

Problem
The peroneal muscles make up the lateral compartment of the leg and receive innervation from the superficial peroneal nerve. The peroneus longus muscle originates from the lateral condyle of the tibia and the head of the fibula. The tendon of peroneus longus courses behind the peroneus brevis tendon at the level of the ankle joint, travels inferior to the peroneal tubercle, and turns sharply in a medial direction at the cuboid bone. The tendon inserts into the lateral aspect of the plantar first metatarsal and medial cuneiform.
A sesamoid bone called the os peroneum may be present within the peroneus longus tendon at about the level of the calcaneocuboid joint. The frequency with which an os peroneum occurs is controversial, with many supporting the idea that one is always present. However, the os peroneum may be ossified in only 20% of the population. The peroneus longus serves to plantar flex the first ray, evert the foot, and plantar flex the ankle.

The peroneus brevis originates from the fibula in the middle third of the leg. Its tendon courses anterior to the peroneus longus tendon at the ankle. It courses over the peroneal tubercle and inserts onto the base of the fifth metatarsal. The peroneus brevis everts and plantar flexes the foot.

Problems may arise in either of the tendons alone, or both may be involved with subluxation. The hallmark of disorders of the peroneal tendons is laterally based ankle or foot pain. Whether the problem is tendinous degeneration or subluxation, the clinical manifestation is pain. With time, loss of eversion strength may occur.

Problems arising with the peroneus longus include tenosynovitis and tendinous disruption (acute or chronic). The os peroneum may be involved with the degenerative process or as a singular disorder and can be fractured or fragmented. Longitudinal tears of the peroneus longus are uncommon but have been reported.
Longitudinal tears of the tendon are the most common problem seen with the peroneus brevis tendon. These may be single or multiple. Tendinitis and tenosynovitis also may occur.

Subluxation of both peroneal tendons may occur following an acute traumatic episode or may be of a more chronic nature.

Frequency
Disorders of the peroneal tendons are less common than other tendon problems involving the Achilles or posterior tibial tendons. However, it is impossible to estimate their true frequency in the United States or abroad.

Etiology
The precise etiology of peroneal tendon disorders depends somewhat on the specific problem being addressed. All disorders may result following a traumatic episode, direct or indirect, with a lateral ankle sprain being the most common trauma. Brandes and Smith have reported that 82% of patients with primary peroneus longus tendinopathy had a cavo-varus hindfoot.3 The presence of an os peroneum also has been postulated to predispose to peroneus longus rupture. Ruptures likewise have been reported to occur secondary to rheumatoid arthritis and psoriasis, as well as diabetic neuropathy, hyperparathyroidism, and local steroid injection.4,5,6
Longitudinal splits in the peroneus brevis tendon appear to result from mechanical factors. Repetitive or acute trauma causes the attritional ruptures. These ruptures may result from an incompetent superior peroneal retinaculum that allows the peroneus brevis to rub abnormally against the fibula.

Overcrowding from a peroneus quartus muscle also has been reported. The blood supply to the tendon has been shown to be adequate.

Subluxation of the peroneal tendons results from disruption of the superior peroneal retinaculum and usually involves avulsion of the retinaculum from its fibular insertion. The mechanism of injury typically involves an inversion injury to the dorsiflexed ankle with concomitant forceful contraction of the peroneals. Some patients have a more chronic presentation and cannot recall a traumatic episode. Congenital dislocations also have been reported. An inadequate groove for the peroneals in the posterolateral fibula may be a cause of subluxation as well.

Pathology of the longus and brevis tendons almost always occurs concurrently. Brandes and Smith noted a 33% incidence of concomitant problems.

Pathophysiology
Brandes and Smith have described and classified primary peroneus longus tendinopathy.3 They present 3 anatomic zones in which the tendon can be injured. Zone A is the level of the superior peroneal retinaculum. Zone B is the level of the inferior peroneal retinaculum. Zone C is the level of the cuboid notch. In their series, complete ruptures were most likely in zone C, while partial ruptures were more common in zone B. In the same study, surgical findings were classified into 3 groups. Group I pathology had no frank rupture but did have adhesions or thickening of the tendon. Group II pathology consisted of partial tears with some continuity of the tendon. Group III had complete ruptures with complete loss of continuity. All group III pathology occurred in zone C.

Other attempts have been made to classify peroneal tendon pathology. Sobel et al have presented a classification for tears of the peroneus brevis tendon as follows:7,8

•Grade 1 - Flattened tendon
•Grade 2 - Partial-thickness split less than 1 cm in length
•Grade 3 - Full-thickness split less than 2 cm in length
•Grade 4 - Full-thickness split more than 2 cm in length
Eckert and Davis have classified superior peroneal retinaculum (SPR) pathology as follows:9

•Grade I - SPR elevated from fibula
•Grade II - Fibrocartilaginous ridge elevated from fibula with SPR
•Grade III - Cortical fragment avulsed with SPR

Presentation
The patient with peroneal tendon pathology typically complains of laterally based ankle or hindfoot pain. The pain usually worsens with activity. However, presentation and diagnosis often are delayed. Patients may or may not recall a specific episode of trauma. Brandes and Smith reported that only 9 of 22 patients with primary peroneus longus tendinopathy recalled an inciting event and that the event was an average of 4.3 months prior to presentation.
Peroneal tendon subluxation or dislocation may present acutely following a traumatic injury to the ankle. However, it is not uncommon for these to present later with an uncertain history of trauma. Patients also may complain of snapping or popping in the ankle.

On physical examination, there usually is tenderness to palpation along the course of the peroneal tendons. Edema also may be present. These disorders require a high level of suspicion. Even frank dislocations may be missed if not specifically evaluated.

A provocative test for peroneal pathology has been described. The patient's foot is examined hanging in a relaxed position with the knee flexed 90º. Slight pressure is applied to the peroneal tendons posterior to the fibula. The patient is then asked to forcibly dorsiflex and evert the foot. Pain may be elicited, or the tendons may be felt to sublux.

Indications
The primary indication for treating these disorders is pain. Nonsurgical treatment usually is attempted first. Failure of conservative measures is an indication for operative intervention.

Operative Considerations

With physical therapy, MRI, and need for primary or secondary repair will be determined based on overal health of the patient, as well as how effective nonsurgical measures have been. If the pain and resolution is not fully noted through physical therapy and bracing one should consider the possiblity of repair. If there are tendon tears associated with the pathology, repair is recommended. If an associated low muscle (peroneus quartius) or ruptured retinaculum is identified, repair is also likely required. We are experts in this pathology, and treat this regularly, and I feel a proper evaluation for this condition will be beneficial to anyone with recurrent ankle sprains, as well as pain in the lateral ankle.

Hammer Toes

2010-05-17T10:04:00.000-07:00

Hammer toe
Hammertoes occur when the smaller toes of the foot become bent and prominent. The four smaller toes of the foot are much like the same fingers in the hand. Each has three bones (phalanges) which have joints between them (interphalangeal joints). The toes form a joint with the long bones of the foot (metatarsals) and it is this area that is often referred to as the ball of the foot.
Normally, these bones and joints are straight. A hammertoe occurs when the toes become bent at the first interphalangeal joint, making the toe prominent. This can affect any number of the lesser toes. In some cases, a bursa (rather like a deep blister) is formed over the joint and this can become inflamed (bursitis). With time, hard skin (callous) or corns (condensed areas of callous) can form over the joints or at the tip of the toe.

What causes hammertoes?
There are many different causes but commonly it is due to shoes or the way in which the foot works (functions) during walking. If the foot is too mobile and / or the tendons that control toe movement are over active, this causes increased pull on the toes which may result in deformity.
In some instances trauma (either direct injury or overuse from walking or sport) can predispose to hammertoes. Patients who have other conditions such as diabetes, rheumatoid arthritis and neuromuscular conditions are more likely to develop hammertoes.

Are women more likely to get the problem?
It is more common in women as they tend to wear tighter, narrower shoes with increased heel height. These shoes place a lot of pressure onto the joint and predispose to deformity. It is common for patients to wear shoes that are too small and this can predispose to the problem. In a study we have performed, 95% of patients were in the wrong size shoes.
Will it get worse?
At the start of the deformity, it is generally mobile which means that the toe can be straightened. However, with time, the joint become fixed or rigid. This can then affect the joint at the ball of the foot and, in severe cases, the joint capsule ruptures (tears) so that the joint becomes dislocated and the toe sits up in the air.

What are the common symptoms?
Deformity / prominence of toe
Pain
Redness around the joints
Swelling around the joints
Corn / Callous
Difficulty in shoes with deformity of the shoe upper
Difficulty in walking
Stiffness in the joints of the toe

How is it identified?

Clinical examination and a detailed history allow diagnosis. X-rays are often not required but can help to evaluate the extent of the deformity and the degree of arthritis within the joint.

What can I do to reduce the pain?
There are several things that you can do to try and relieve your symptoms:
Wear good fitting shoes with a deep toe box
Avoid high heels
Use a toe prop to straighten the toe if it is still mobile
Wear a protective pad over the toe
See a doctor at the Family Foot and Leg Center.

What can we as a specialist do to correct or reduce your symptoms?
If simple measures do not reduce your symptoms, there are other options:
Advise appropriate shoes
Advise exercises if the toes are still mobile
Show you how to strap the toe in a corrected position
Provide a splint or protection
Consider orthotics

Advise on surgery
The way in which your foot loads during walking can place increased stress on the ball of the foot and cause increased toe activity. Special shoe inserts (orthoses) can help to control foot movement. Whilst these are unlikely to resolve established deformity they may help reduce discomfort in the ball of the foot.

Will this cure the problem?
If the deformity is mobile, then this may help prevent progression although there have been no scientific studies to analyse the benefit. If the deformity is fixed, then orthotics will not cure the problem but may reduce the associated symptoms.

What will happen if I leave this alone?
Generally, the deformity becomes worse with time and slowly becomes fixed (stiff). This can cause discomfort in shoes. The position of the toe places increased stress on the ball of the foot and this can become painful. Corn and callous formation on the ball of the foot is not uncommon. In some cases, the metatarsophalangeal joint capsule ruptures, causing the toe to sit up in the air.

Can the deformity be reversed or cured?
The only effective way of correcting the deformity is to have an operation.

How does the operation correct the deformity?
There are a number of different operations. However, the most common operations are:
Tendon transfer
Digital arthroplasty
Digital arthrodesis
Tendon transfers involve taking the tendon from under your toe and re-routing it to the top of the toe so that the toe is pulled down. This can be used alone if the toe is mobile or in combination with the other two procedures. This can leave the toe a bit swollen and stiff.
Digital arthroplasty and arthrodesis involve the removal of bone from the bent joint to allow correction. An arthroplasty removes half the joint and leaves some mobility whilst an arthrodesis removes the whole joint and, following a period of time with a wire/pin protruding from the end of the toe, leaves the toe rigid.
In more severe cases, the tendon on the top of the toe and the joint at the ball of the foot need to be released to allow the toe to straighten. If there is severe stiffness at this joint, then the base of the bone at the bottom of the toe (phalanx) may need removing (basal phalangectomy) or the metatarsal shortened (Weil osteotomy).

Patients will often tell me this: "I have heard it is very painful."
The nature of surgery means that there will be pain and swelling, usually worse the night after surgery. However, with modern anaesthetic techniques and pain killers, this can be well controlled. The level of pain experienced varies greatly from patient to patient with some experiencing no significant discomfort.

Will I have to have a general anaesthetic (be asleep)?
Not if you did not want one. Many of these procedures are performed perfectly safely under local anaesthetic (you are awake). Some patients worry that they may feel pain during the operation but it would not be possible to perform the operation if this were the case. We often perform these procedures at our surgical suite over at the Gridley Building location, where often times these procedures are done within 30 minutes, and you leave right then in a surgical shoe with the dressing applied immediately after the procedure is completed.

Will I have to stay in hospital?
No. As long as you were medically fit and have adequate home support, many patients are able to have this type of operation performed as day surgery and go home.

Will I have to have a plaster cast?
Plaster casts are generally not required for this type of surgery.

Are there a lot of complications?
There are risks and complications with all operations and these should be discussed in detail with your specialist. However, with most foot surgery it is important to remember that you may be left with some pain and stiffness and the deformity may reoccur in the future. This is why it is not advisable to have surgery if the deformity is not painful and does not limit your walking. A thorough examination of your foot and general health is important so that these complications can be minimised.
Although every effort is made to reduce complications, these can occur. In addition to the general complications that can occur with foot surgery, there are some specific risks with toe surgery:
Persistent swelling which may be permanent
Recurrence of deformity / corn (this tends to be more of a problem with the little toe)
Regrowth of removed bone
Residual pain
Stiffness or flail (floppy) toe
The toe may not sit on the ground – floating toe (there is an increased risk of this with arthrodesis)
You may get discomfort in other parts of your foot during the recovery period. This generally settles.
There is always a possibility that the deformity may return in later life.

When will I be able to walk again and wear shoes?
In the majority of cases, you will able to walk with the aid of crutches within 2-4 days but you will remain somewhat limited for the first 2 weeks.
Some patients are able to return to wider shoes within two weeks with 60% of patients in shoes at 6 weeks and 90% in 8 weeks. This period is longer for arthrodesis as shoes cannot be worn until the wire/pin has been removed (generally 3-6 weeks).
Swelling generally starts to reduce at 6-8 weeks and the foot will be beginning to feel more normal at 3 months although the healing process continues for 1 year.

When will I be able to drive again?
When you feel able to perform an emergency stop. This is generally between 4-8 weeks post operatively but you should always check with your insurance company first.
When will I be able to return to work?
If you are able to get a lift and have a job that is not active and you can elevate your foot, you may be able to return after 1-2 weeks. Generally, patients return to work between 4-8 weeks depending on the type of job, activity levels and response to surgery.
When will I be able to return to sport?
Although the healing process continues for up to 1 year, you should be able to return to impact type activity at around 3 months. This will depend on the type of operation you have and how you respond to surgery.

Hopefully this is an effective run down of various questions commonly asked by my patients here, and if you come up with more please comment and the questions will be answered.

NAIL LASER UPDATE

2010-04-27T04:38:00.000-07:00

Onychomycosis is a common infection of the nail, and it may affect approximately 6.5% to 8.7% of the North American population. Visual description includes: yellowed, discolored, thickened and flakey nail / nail debris. The fungus causes a breakdown of the keratin within your nail plate. The byproduct is termed subungal debris which harbors both keratin and fungal elements. The same fungus that is responsible for toenail fungus is also responsible for athletes feet aka tinea pedis. An infected nail can act as a breeding ground for recurrent athlete's feet and mold.

The Family Foot & Leg Center is now proud to present the custom , gentle cool touch laser for your fungal nails in addition to keryflex total nail resurfacing technology.

http://www.gentlenaillaser.com/resources/BeforeAfter.pdf

Why the cool touch laser vs others? The cool touch uses a 1320 nm beam, a much safer and cooler beam than the 1064 nm of the competition. For additional safety and comfort, a cryogen spray is used when the nail is heated to the optimal treating temperature. A large 10mm beam diameter, controlled depth provides a reproducible safe procedure while treating the offending pathogen.
The laser is not new to the medical profession, but the use in treating fungal nails has picked up steam recently as additional research is being done. Lasers have been used for vein removal, wart distruction, removal of fine lines / wrinkles, hair, acne and tatoo removal. We at the Family Foot and Leg Center (FFLC) have done our research into various laser modalities currently on the market and has found the 1320 nm laser by cool touch to be the most effective and gentle on the nail bed but tough on fungal cells. We also have a 1064 nm laser (similar to the competition) but we reserve such for spider veins and less sensitive areas.

Initially, a comparison was made between the Noveon and Pinpointe lasers. With more research,different promising options became clear that combined superior treatment and safety features. While the Noveon was promising, it failed its initial FDA approval for onychomycosis and ran into financial problems. Additionally, some of the lower wavelengths had questionable results and the safety features with the Noveon added additional costs to the procedure. As of this writing, the Noveon is not available but may be in the future. It should also be noted that the laser also was initially developed for dental procedures. All of the lasers mentioned here have been FDA cleared for podiatry, dermatology and general surgery use. So they are appropriate for toenail treatments if proven worthy by your doctor.

As research proceeded, Dr. Katz liked the Cooltouch CT3 Plus Zoom laser, one of the most proven lasers on the market today with a track record. The Cooltouch allows for various types of skin treatments for many issues. Dr. Katz points out that toenails are simply modified skin, so the Cooltouch laser makes sense. He also liked the higher wavelength of the beam and feels that the hard thick nail can be more safely penetrated and treated with this different wavelength. In addition there are added features that improve the appearance of the nail by resurfacing, similar to skin resurfacing and rejuvenation. This is only a Cooltouch feature.

The CoolTouch CT3Plus CoolBreeze produces 1320nm laser energy that is specifically absorbed by water and water associated with collagen in the tissues of the nail matrix. The laser is so sophisticated that it can detect and reach the proper target temperature set by the doctor leading to death of the fungus. The treatment then stops immediately and then the nail is cooled with a spray. This allows for fungal death without damaging the skin or the nail growth plate. Cooltouch's impeccable safety emanates from its incorporating pulsed cooling and real-time temperature feedback into its treatments. In addition, the CoolBreeze Handpiece features an adjustable spot size from 3 mm to 10 mm allowing for adjustments based on nail size for most effectiveness. Other lasers currently being used do not incorporate these advanced features for patients leading to less desirable outcomes and minimal safety features. The Cooltouch laser can be completely controlled. The treatment temperature to kill the fungus can occur automatically while incorporating safety. Each patient can receive a customized treatment leading to the best possible outcome. This is truly unique.

There are different growth phases of the nail and fungus and the best results occur when the patient receives at least 2 treatments. The cost of 2 treatments with the Cooltouch is usually the same or less compared to only one treatment with the Pinpointe laser. This certainly benefits the patient.

Dr. Katz feels that the laser is superior to all other remedies for fungal toenails. However, patients need to follow a comprehensive maintenance regimen to prevent recurrence of the toenail infection.

Forfoot Deformity

2010-03-17T05:29:00.000-07:00

A bunion is essentially a shift of the toe bones into the improper position causing pain and loss of function. The deformity involves the big toe and the long bone behind the big toe, the 1st metatarsal. Over time, the 1st metatarsal will begin to move towards the other foot (medial) while the big toe will move out of joint towards the 2nd toe (lateral). As the end of the 1st metatarsal bone begins to stick out, it will be under pressure from shoes and the ground. This constant pressure and friction will cause extra bone formation, leading to the bump that is seen on the side of the foot. The big toe will continue to shift towards the second toe causing an unbalanced big toe joint. Over time arthritis can develop in the joint due to the mal-positioned joint. A bunion deformity is always progressive. It will always get worse over time.

Severe bunion deformity with shift of the great toe under the second toe and hammertoe of the second toe.

Symptoms:
A bunion deformity does not always have to be associated with pain. Some patients have a very severe deformity and no pain, while others with a mild deformity have severe pain. Patients usually will have pain right over the bump with continued irritation and bruising to the bone from shoe gear and the ground forces. As the deformity progresses, pain will then be noticed in the joint itself when the big toe is moving. The big toe is very important during the gait cycle for pushing off the ground. With this imbalance of the joint there is a loss of the proper range of motion of the big toe joint leading to an inefficient gait. Over time arthritis will develop in the joint as the cartilage is scraped away each time the joint moves. The pain can be of different degrees depending on the degree of deformity, shoe gear, and activity level.

Causes:
Bunions are usually a genetic deformity. There is an imbalance of the muscles and the ligaments that are holding the 1st metatarsal in place. As this joint becomes weaker over time, the long metatarsal bone will begin to shift medially. The big toe is then under stress and begins to shift laterally under the pressure of the joint and shoes. Shoes with a tight and narrow toe box can help to create and make a bunion worse over time. High heeled shoes can also worsen and cause a bunion. Patients will a flat foot type (pronation) have a higher chance of having a bunion in the future.

Symptoms:
A bunion deformity does not always have to be associated with pain. Some patients have a very severe deformity and no pain, while others with a mild deformity have severe pain. Patients usually will have pain right over the bump with continued irritation and bruising to the bone from shoe gear and the ground forces. As the deformity progresses, pain will then be noticed in the joint itself when the big toe is moving. The big toe is very important during the gait cycle for pushing off the ground. With this imbalance of the joint there is a loss of the proper range of motion of the big toe joint leading to an inefficient gait. Over time arthritis will develop in the joint as the cartilage is scraped away each time the joint moves. The pain can be of different degrees depending on the degree of deformity, shoe gear, and activity level.

Diagnosis:

A clinical examination of the foot is done first. It is very important that the structure and biomechanics of the patient’s entire foot is examined. In order to identify the severity of the deformity, the stability of the joints around the bones involved is essential. The doctor will analyze the gait pattern of the patient. The doctor will identify if there is pain with joint movement and if the big toe can easily be re-located back into the joint. X-ray evaluation is essential in order to determine the degree of the bone shift and specific angles and the relationships between the bones.

Treatment Options:
Conservative treatments for bunions are limited. Wider shoe gear and accommodation for the deformity can be used to take the pressure off the area. Bracing and spacers are often used to brace the big toe back into position and can take some of the pressure of the big toe. However, this does not address the deformity and shift in the metatarsal bone. Furthermore, the bracing techniques are only work when used, once the brace is removed, the big toe will immediately go back into its deformed position. Custom molded Orthotics can take some pressure off the big toe and redistribute the forces of the ground through the rest of the foot. Orthotics can slow the progression of the deformity. There is no way to stop the progression or reverse the deformity without literally moving the bones back into the correct position and realigning the joint. This can only be accomplished through surgery.

We know that in order to realign the joint, the first metatarsal must be repositioned and fixated in the proper position. This can be accomplished by three basic types of procedures. First MPJ fusion, Offset Austin and Lapidus bunionectomy are the ideal procedures as they limit the chance of the bunion deformity from returning.

The choice of the procedure to be performed will be dictated by the severity of the deformity.

Mild Bunion Deformity
In mild and moderate bunion cases, we try to allow patients to have a more rapid recovery and limit the amount of time they need to spend off their feet. The Tightrope and Offset Austin bunion procedures allow immediate weight on the foot in a boot and also allow for rapid return to shoes. The choice of procedure best for each patient depends on the deformity size, the stiffness of the 1st metatarsal and the ease of realignment of the 1st metatarsal during the clinical exam.

Drawing of a bunoin prior surgery. Note poor alignment of the great toe and the 1st metatarsal. Grey shaded are will be removed during surgery and dotted line shows the region of bone cut.

Drawing of bunion after surgery. Note the shift of the 1st metarsal towards the second meatarsal for realignment of the column and fixation of the bones together with the two screws from top to bottom.

Clinical representations of pre and post surgery of mild bunion corrections.

Severe Bunion Deformity
In severe bunion cases, the 1st metatarsal is dramatically shifted away from the second metatarsal and there is looseness of the 1st metatarsal at the base of the bone. This is a difficult problem to correct unless the entire 1st metatarsal is realigned and held stable so it does not shift again. The Lapidus procedure allows for the 1st metatarsal to be repositioned with ideal correction and limited to no chance of bunion return. Recovery is slightly more difficult due to the need for crutches but the result is well worth it in difficult and severe cases. Some patients even require fusion of the first metatarsophalangeal joint secondary to this variation of deformity.

Hypermobility

The underlying cause of severe bunions is thought to be at the medial cuneiform joint and not at the great toe joint. If there is looseness of the medial cuneiform joint, there is motion of the metatarsal allowing the metatarsal to move out of position resulting in a bunion. The metatarsal may also move up resulting in poor position on the ground and collapse of the arch.

Clinical Pictures

Orthopedics versus Podiatrics

2010-03-08T08:00:00.000-08:00

This is a common question that I will encounter, and I thought I would enlighten our readers about how I tend to answer this:

Who is better for foot and ankle treatment, a podiatric surgeon or orthopedic surgeon ?

This is a long debated topic which spans several other forums, and may actually not have a defined answer in general. I feel this question would be best answered in paragraphs headed, "it depends".

"It depends" on training.

I will offer several reasons for this statement. The first being that not all orthopedic surgeons have the same training. The same holds true for podiatric surgeons. Some podiatrists are not surgically trained, and a pathology may require such an intervention. Many orthopedic doctors tend to spend more time on knees and hips, some have fellowships in shoulders and foot and ankle surgery training is minimal as a general rule. Surgically trained podiatrists must have ABPS board qualification or certification for adequate credentials, especially for more complex surigcal needs of patients, such as ankle fusions or calcaneal fracture open reductions. These podiatrists spend 3 years doing complex foot and ankle surgery and some even have an additional year of fellowship training as well.

Most podiatrists feel comfortable treating forefoot deformities like bunions and hammertoes, and if they have surgical priveleges they may treat these conditions quite well. Many orthopedic surgeons will not routinely treat foot and ankle conditions that podiatrists see in their offices every day. The few that are fellowship trained in foot and ankle surgery are more apt to treat these various conditions without too much trouble. Overal, if you are researching a new doctor for your feet, I believe it is necessary to know the qualifications of your doctor prior to making the appointment.

"It depends" on your problem.

If you suffer from heel pain, or nail issues, most podiatrists are able to effectively treat these conditions quite efficiently without surgical interventions. Again, if a blade is part of the treatment protocol needed to relief painful symptoms, it may be necessary to know what boards your doctor is part of. All of the podiatrists at FFLC are ABPS qualified, and that means we are able to surgically treat any foot and ankle condition. If you choose to go the orthopedic route for your care, you may need to know whether the physician has a fellowship in foot and ankle and is commonly seeing people for their feet issues.

We see the most common problems for foot and ankle pain here, as well as some of the most complex problems. We do this every day and that's all we do. Experience and volume speaks well for the abilities of our doctors to not only treat these conditions well, but treat them often.

MicroVascular Therapy (MVT)

2010-02-24T06:11:00.000-08:00

With poor circulation, nonhealing wounds, post surgical pain, and pain from neuropathy comes a multitude of treatment options and medications for the problem. There are also physical therapy modalities to help enhance the body's natural healing potential. Such a therapy as this is contained within MVT. We have a multitude of patients undergoing this modality, and have had strongly positive results with various indications as listed above. Here is just some of the information available and the likely mechanism of how it works:

MVT is a physical medicine modality which
addresses the problem from a different
perspective: working directly and mechanically
to move blood flow through neuromuscular
stimulation of the venous muscle pump.
In MVT, a MicroVas Vascular Treatment
System generates ionic impulses which pass
through the body, or its extremities, using
strategically placed carbon emitter pads. The
pads are positioned 180° from each other in
groups of up to 8 pairs. The ionic impulses pass
completely through the limb or body, creating
neuromuscular stimulation of the venous
muscle pump, and simultaneously upregulating
the metabolic process.

While very little information exists
concerning the MVT mechanism of action or
efficacy, one study of 25 diabetics1 shows
encouraging results.
While the 48% average increase in TcPO2 for
patients after one 45 minute treatment is
dramatic, the 157% increase in baseline TcPO2
for patient number 4, suggests that the benefits
of treatment are cumulative and perhaps longlasting.
It is postulated that this is the result of
angiogenesis, or perhaps the reversal of stenosis
brought about through the repeated pulsations
with increased blood flow and increased
hydrostatic pressures.

In terms of limb salvage, there may be the single
most dramatic example. A case study deomonstrates in
week one, with a TcPO2 reading of 0 before
treatment and 2 after treatment, he represented
an unsalvageable limb. After four weeks of
treatment, he still reads only 3 before treatment
and 8 after treatment: quite an improvement,
but still not a salvagable limb. Following
treatment in the eighth week, however, he
reached a reading of 35—very likely a
salvageable limb!

While data regarding microvascular therapy
as applied in peripheral neuropathy are scarce,
initial findings show promise.
Patients were referred to a clinic by
neurologists, vascular and orthopedic surgeons
as well as family practitioners, all of whom had
depleted their pharmacological armamentarium
on these patients without results.2
Patients were 71% female (40), 29% male
(16) and ranged in age from 58 to 80. Both
diabetic (88%) and non-diabetic neuropathy
(12%, unknown etiology) were represented.
(MVT has been used in other studies on
chemotherapy-inspired neuropathy).

Not shown in the data, but of significant
importance is the patient response to MVT,
which included a reduction or elimination of
drug use.

Can a relatively short regimen of physical medicine actually reverse
neuropathy without addressing the underlying causes? Are the apparent
improvements shown in these limited trials transient or long-lasting?
There is a need for long-term studies. In a recent article, King and
Veves of Harvard Medical School said, ”an urgent need exists to
develop new therapeutic approaches that will improve nerve function
in diabetic patients”. Perhaps MVT is that new therapeutic approach.

Peripheral Neuropathy

2009-12-17T06:22:00.000-08:00

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

2009-09-28T10:56:00.001-07:00

'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

2009-09-17T12:27:00.000-07:00

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

2009-09-15T07:33:00.000-07:00

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

2009-09-13T17:15:00.000-07:00

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)

2009-08-12T11:59:00.001-07:00

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

2009-08-09T09:39:00.000-07:00

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

2009-06-27T11:17:00.000-07:00

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.