Tough Heel Pain

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

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

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

Extra Corporal Shockwave Therapy

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

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

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

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

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

Fungus Amongs't Us

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

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

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

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

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

Simple tips to prevent fungus infection:

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

Big Toe Pain

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

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

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

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

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

Tennis Time and Common Injuries!

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

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

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

Ankle sprains

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

Z - Coil Is HERE!!

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)

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

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.