5 Facts about Charcot Neuroarthropathy you need to know

1) With an unknown definitive mechanism of incidence, this disease process has many proposed hypothetical mechanisms currently in clinical practice. Some believe that increased inflammation and microfracturing of the bone secondary to sensory loss are key components, others believe glucose levels and specific traumatic events are responsible for this process which are compounded by inability to offload and protect the injured limb leading to progressive breakdown of the bone. We all agree that these elements are part of the problem, but do not necessarily occur in all cases. Especially in non diabetics with the disease of Charcot neuroarthropathy.

2) We know that many cases start with increased warmth, redness, and swelling. Unfortunately not ALL cases give us this "textbook" presentation.

3) We also know that characteristic radiographic changes may occur.  And when they do, differing mindsets and clinical approachs are valid and are practiced routinely in my practice. If an ulceration is present, or progressive radiographic changes are found, surgery is likely required for limb salvage.

4) We generally understand that patients with low or no protective sensory threshold on their feet tend to have a higher incidence of this process.  Also patients that have poor glucose control and are obese tend to have this same increase in incidence. Edema and general leg swelling in diabetic patients with Hemoglobin A1c levels higher than 8.0 tend to have increased risk of Charcot development in their feet. Usually all of these patients have good blood flow with regards to arterial circulation, but may have venous or lymphatic flow compromise.



5) Not all patients with Charcot neuroarthropathy are diabetic. I have treated many patients whom are not diagnosed with diabetes, and did not present with red swollen foot, who developed Charcot neuroarthopathy with radiographic bone degradation and resultant foot deformity. These patients do tend to have profound sensory polyneuropathy of unknown etiology (idiopathic) and are still at risk given the above listed requirements. I have had to reconstruct several patient's feet without diabetes as an underlying diagnosis, and it seems that they tend to have less overall complications but are still prone to the neuroarthropathy nonetheless.



The take away from this blog is that many of the "facts" about this disease process have some "grey area" information. You should seek the expert opinion with good experience in this disease process prior to any surgical intervention or decision for lower leg or foot amputation. The doctors at FFLC are well equipped to accommodate and treat this condition and are well versed in all avenues regarding limb salvage.

External fixation here in Naples Florida

External fixation may look very high-tech, and maybe even scary.  However, external fixation has been used in one way or another since almost 2400 years ago.  External fixation techniques were described by Hippocrates, and were used in treating tibia fractures.  External fixation is a minimally invasive technique to reduce displaced fractures and has become a very important part of deformity correction and nonunion and pseudo arthrosis repair as well.

Jean François Malgaigne was one of the many pioneers that made advancements with external fixation devices.  In 1846, Malgaigne used a device that consisted of a clamp and four metal prongs to reduce and stabilize a fracture of the patella, or kneecap.  Following this external fixation device many other similar inventions were used to treat fractures in various locations.  In 1938, Raoul Hoffman made advancements that made external fixation even more useful, and allowed surgeons to place pins into a fracture for stabilization with guidance, while being minimally invasive.  In 1951, Dr. Gavriil A. Ilizarov developed the external fixation device that is still in use today.  Ilizarov’s fixation device consists of a metal frame that encircles the limb, and is attached to underlying bone by pins.  Threaded rods and hinges allow movement of the bone to the correct alignment.  Ilizarov’s external fixator is great because adjustments can be made without opening the fracture site, and the device provides stability. Also it can be converted to internal fixation once the soft tissues have become less swollen. 

Modern day external fixation not only provides stability to a fracture, but can also be used for soft tissue deformities, as well as other bony deformities.  External fixation is preferred when slow correction is required, and even more useful in high risk patients with vascular disease and even open fractures with high risk of infection.  The chance of getting a blood clot is lessened because with external fixation patients can be partial weight bearing, or weight bearing as tolerated following the procedure due to the stability that the fixation provides.  External fixators have been used for other bony deformities, such as Charcot, ankle arthritis, and clubfoot.  External fixation can also be used to lengthen amputated foot and toe stumps.  External fixation has definitely helped many people, but there are still some cons.  Pain and infections are two issues associated with external fixation, and rates vary depending on the extent of the procedure, and the location of the device.  External fixation devices are used by specially trained physicians and all three of the doctors at FFLC are capable of utilizing these various techniques for patients that require such interventions.  

Brian Timm, DPM, FACFAS

Board Certified by the American Board of Foot and Ankle Surgery in Foot and Reconstructive Rearfoot and Ankle surgery

Swimming and your feet

Everyone is starting to return to Florida for the seasonal upgrade in weather.  Fire up the pool warmer, and get ready to swim.

 Swimming is known for being an activity that is less damaging to the joints of the knee, foot and ankle, and can even offer a means of exercise for athletes of other sports with certain foot injuries!

Just about the worst thing a runner can hear is that they are injured and going to have to take time off from running.  Luckily, swimming can help soften this blow by offering an alternative way to get some cardiovascular activity.  Stress fractures are small fracture that occurs from excessive force on normal bone and can force runners to talk a break from running for several weeks.  For the runner with a stress fracture, swimming is often a great alternative that will not bear weight on the injury.  Swimming can also help an athlete ease back into their favorite sport after other serious injuries.  For example, after a peroneal tendon tear, swimming can help to make the transition from being immobilized in a cast or a CAM walker boot to normal running or other weight bearing sports go more gently by allowing the muscles to slowly adapt.  

Swimmers should also be careful to take care to avoid injuries that can occur from intense pool training.  Ankle pain is a common complaint from the repetitive motion the ankles are forced through while swimming.  The Achilles tendon, which is responsible for flexing the foot, may also become irritated from the repetition and develop Achilles tendonitis.  While the Achilles is doing much of the work, the extensor tendons on the top of the foot can also become irritated by being tightly pulled.  By taking care to stretch the feet and ankles properly and always listen to your body when working out, these injuries can be minimized.  Swimmers also need to take extra care to avoid developing warts, Athlete’s foot, and fungal nails from bacteria and fungus that may live in locker rooms and poolside surfaces where other bare feet have deposited them.  If these conditions do develop, see us at Family Foot and Leg Center for an urgent evaluation, as to help prevent spread to others. 

Dr Timm, DPM, FACFAS

Board Certified by the American Board of Foot and Ankle Surgery in Foot and Reconstructive Rearfoot and Ankle Surgery.

Limb Preservation: Total Contact Casting

Diabetics with neuropathic ulcers affect at least one quarter of all diabetics in the United States, and according to Wounds Research, approximately 1 in 5 of these individuals will eventually require an amputation of their foot. Total contact casting has recently become more popular as an option for foot protection, and to mediate the excessive wear and tear that some diabetic foot sores suffer.

What is total contact casting?

As the name suggests, this technique, which is used by many diabetic foot specialists, is a thin cast that is applied to the entire plantar surface area of the foot, as well as the lower leg. Based on its design, the cast can take up as much at 92 percent of the pressure from the ulcer site. Since ulcers often occur on parts of the foot or leg that are repeatedly impacted through daily movement, it is important that they receive as much padding as possible without affecting an individual’s normal walking patterns. Although total contact casting provides relief from certain pressures, the cast works with the natural human gait to make sure that no section of the foot or leg is required to take on excessive weight or pressure.

Does it always work?

Total contact casting has been shown to be effective in the healing of foot and lower leg ulcers, but only those that are noninfected. According to current research, the success rate is between 72 and 100 percent in most patients. A study conducted at the University Hospital Maastricht in the Netherlands examined how total contact casts would fare on infected patients, and of the 28 patients in the study group, only 36 percent showed signs of healing. The study group recommended that individuals with infected diabetic ulcers look toward alternative treatments for healing, according to the American Diabetes Association.

Surgery may become necessary in conjunction with acute infections.

Overview of the Charcot disease

What is it?

Charcot arthropathy, also known as Charcot foot and ankle, is a syndrome in patients who have neuropathy or loss of sensation. It includes fractures and dislocations of bones and joints that occur with minimal or no known trauma.​

Symptoms and Clinical Presentation

​Initially, there may be swelling, redness and increased warmth of the foot and ankle. Later, when fractures and dislocations occur, there may be severe deformities of the foot and ankle, including collapse of the midfoot arch (often called rocker bottom foot) or instability of the ankle and hindfoot. The syndrome progresses through three general stages:

•Stage 1 (acute, development-fragmentation): marked redness, swelling, warmth; early radiographs show soft tissue swelling, and bony fragmentation and joint dislocation may be noted several weeks after onset
•Stage 2 (subacute, coalescence): decreased redness, swelling and warmth; radiographs show early bony healing
•Stage 3 (chronic, reconstruction-consolidation): redness, swelling, warmth resolved; bony healing or nonunion and residual deformity are frequently present.

Cause (including risk factors) 

Charcot foot occurs in patients with peripheral neuropathy resulting from diverse conditions including diabetes mellitus, leprosy, syphilis, poliomyelitis, chronic alcoholism or syringomyelia. Repetitive microtrauma that exceeds the rate of healing may cause fractures and dislocations. Changes in circulation may cause resorption of bone, weakening the bone and increasing susceptibility to fracture and dislocation. 

Anatomy 

Charcot arthropathy may affect any part of the foot and ankle, including (in decreasing order of frequency) the midfoot, hindfoot, ankle, heel and forefoot.  Multiple regions may be involved concurrently.  Fractures and dislocations frequently involve several bones and joints, with extensive fragmentation and deformity. 

Diagnosis 

Time between onset of symptoms and diagnosis may be several weeks or months. Delay in diagnosis may or may not affect the end result because gross instability may occur even if prompt diagnosis is made. Diagnosis is based on a high index of suspicion for this problem in patients with neuropathy. Increased redness, swelling and warmth may be the only early signs. Some patients have pain. Early radiographs may show soft tissue swelling with no bony changes, but repeat radiographs several weeks later may show bone and joint changes.

Treatment Options 

Non-Surgical: Non-operative treatment includes a protective splint, walking brace, orthosis or cast. Early weightbearing is allowed in stage 1 by 41 percent of specialists and in stage 2 by 49 percent of specialists, and other specialists recommend non-weightbearing. After stable healing is noted in stage 3, treatment includes accommodative footwear with protective orthoses.Surgical: Selected patients with instability in the early stages may be treated with open reduction and internal fixation and fusion. In the later stages, surgical options may include realignment osteotomy and fusion (correction of deformity) or ostectomy (removal of bony prominence that could cause an ulcer ). 

* Sometimes the surgery can fail, and this is commonly because of improper or inadequate fixation, poor glucose management, obesity, noncompliance, and even infection. 

Charcot and you.

Many diabetic patients may have heard warnings to look out for “charcot foot” but they may not know exactly what this means.  Different from diabetic charcot foot is an inherited disease with another characteristic foot type called Charcot-Marie-Tooth disease.  As a part of September’s Charcot-Marie-Tooth (CMT) disease awareness month, it is critical for patients to understand the differences between these two neurological disorders. 

CMT

Charcot-Marie-Tooth disease is caused by a gene defect that is often inherited.  If CMT is seen in other family members, parents should be on the lookout for the development of slowly progressing muscle weakness in the lower extremities before age 20.  Individuals with CMT have nerves that lose their myelin covering, which normally allows signals to be sent to and from skin and muscles at a normal speed allowing sensation and muscle contraction.  Patients will not usually complain of any numbness because their sensation was likely never completely normal.  As a result of the weakness and loss of sensation, first in the legs then typically seen in the upper extremities, kids with CMT may seem clumsy and have difficulty walking without tripping or rolling their ankles. The feet will often have a high arch appearance and may be prone to ulcers from damage caused by lack of ability to sense pain. 

Diabetic Charcot Foot

Patients with diabetes need to be concerned about charcot arthropathy when they develop areas of the foot where they can no longer feel anything.  The combination of lack of sensation allowing damage to the foot that patient cannot feel and an increased blood flow supplying mediators of the inflammatory process allows a “charcot joint” to develop.  In the charcot joint, the repeated small injuries occurring cause bones to gradually fracture and dislocate.   This causes deformity (often an extreme flat foot) which typically places the diabetic patient’s foot at a greatly increased risk of developing ulcers and subsequent infection with severe consequences.  The most common signs of the development of charcot arthropathy are swelling and increased temperature of the affected area of the foot, redness, pain and the feeling of a “loose bag of bones” when the joint is moved. 

In both diabetes with loss of sensation, and Charcot-Marie-Tooth, foot self-exams are immeasurably important in preventing ulceration and further complications.  Protective shoe gear and custom made orthotics can provide additional protective measures for the foot.  As shown by these two disease processes, loss of sensation in the foot is a major problem that should always be evaluated by your foot and ankle specialists here in Naples Florida.  

Will 3D custom foot orthotics help you?

Orthotics are devices that are placed in the shoe to put the foot in a neutral position, or provide cushioning depending on the type of orthotic.  Orthotics devices are used in foot conditions such as, flat foot, pes cavus (high arched feet), equinus (muscular imbalance limiting upward motion of foot), hammertoes, limb length difference, diabetes, bunions and many other conditions.  Orthotics can be custom made or bought over the counter.  A 3-dimensional scan of the foot is used to send to a lab that makes custom made orthotics, and the orthotics lab can add correction specific to the patients’ needs based on specific instructions in the form of a prescription from our offices.

Orthotics fall into two different categories: functional and accommodative:  

Functional orthotic devices are used to correct biomechanical deformities in the frontal plane, and reduce impact while running or walking.  Functional correction is used to reduce abnormal pronation by providing support of the arch, while accommodative orthotics are a soft supportive device used to provide cushioning, and distribute weight bearing pressures evenly across the bottom of the foot.  When making orthotics it is important to compensate for limb length differences because even a small difference can cause pathology, and affect gait.  Symptomatic differences in limb length usually occur when there is a 4cm or greater difference.  Functional orthotics devices are made of semi-rigid material to provide stability, such as graphite or plastic.  

Accommodative orthotic devices are usually made of softer materials, such as leather or foam to provide comfort.  Accommodative orthotics devices are used in conditions such as diabetes and rheumatoid arthritis to help relieve pressure and apply gentle offloading forces away from prominent structures of the foot. 

This is just a brief overview of the various uses and types of orthotics, and is not complete by any means.  For some people, orthotics devices are a way to treat foot pain conservatively and avoid surgery.  Orthotics devices are sometimes recommended post-operatively to prevent recurrence of various deformities.  However, some patients use orthotics devices to provide stability and support to the foot, and prevent injuries.  

Here, we have a 3-dimensional scanner which can allow us extremely accurate impressions of the feet in order to achieve both optimal comfort and control with our custom molded devices. 

Orthotics, also known as orthoses, refers to any device inserted into a shoe, ranging from felt pads to custom-made shoe inserts that correct an abnormal or irregular, walking pattern. Sometimes called arch supports, orthotics allow people to stand, walk, and run more efficiently and comfortably. While over-the-counter orthotic are available and may help people with mild symptoms, they normally cannot correct the wide range of symptoms that prescription foot orthoses can since they are not custom made to fit an individual's unique foot structure.

Orthotic devices come in many shapes, sizes, and materials and fall into three main categories: those designed to change foot function, those that are primarily protective in nature, and those that combine functional control and protection.
Rigid Orthotics
Rigid orthotic devices are designed to control function and are used primarily for walking or dress shoes. They are often composed of a firm material, such as plastic or carbon fiber. Rigid orthotics are made from a 3-dimensional scan of the foot or feet. Rigid orthotics control motion in the two major foot joints that lie directly below the ankle joint and may improve or eliminate strains, aches, and pains in the legs, thighs, and lower back.

Soft Orthotics
Soft orthotics are generally used to absorb shock, increase balance, and take pressure off uncomfortable or sore spots. They are usually effective for diabetic, arthritic, and deformed feet. Soft orthotics are typically made up of soft, cushioned materials so that they can be worn against the sole of the foot, extending from the heel past the ball of the foot, including the toes. Like rigid orthotics, soft orthotics are also made from a 3-dimensional scan of the foot.
Semi-Rigid Orthotics
Semi-rigid orthotics provide foot balance for walking or participating in sports. The typical semi-rigid orthotic is made up of layers of soft material, reinforced with more rigid materials. Semi-rigid orthotics are often prescribed for children to treat flatfoot and in-toeing or out-toeing disorders. These orthotics are also used to help athletes mitigate pain while they train and compete.

If there is any question whether these sorts of devices may help you, most likely than can, because if you are questioning if you need them most likely your feet have some symptomatic concern which does require an evaluation.

Brian Timm, DPM, FACFAS

Board Certified by the American Board of Podiatric Surgery

6 Secrets to Manage Foot Arthritis

Arthritis is the leading cause of disability in the United States.  Almost half of people in their sixties and seventies suffer from arthritic foot pain.  There is no cure for arthritis, but there are many types of treatments available that focus on pain management.  Osteoarthritis typically occurs in older individuals, or people that have had a previous injury.  Osteoarthritis is a degenerative joint disease. Over time the cartilage between joints wears down leading to inflammation, swelling, and pain.  In younger individuals that develop osteoarthritis there is usually a history of previous injury, family history of osteoarthritis, or obesity.  

The foot consists of 33 joints, but there are a select few that are more prone to osteoarthritis than others.  The ankle, the great toe, 3 joints in the hindfoot (talocalcaneal, calcaneocuboid, talonavicular joints), and the midfoot (metatarsocuneiform joint) are the most commonly affected joints.  Osteoarthritis can also be caused by abnormal foot structure, such as flat foot or a high arch.
Some people believe that cold, damp weather exacerbates their osteoarthritis, and some even say they can predict the weather.  Common symptoms of osteoarthritis include: stiffness, limitation of the joint, swelling, difficulty walking and tenderness that is persistent.  Osteoarthritis is a chronic condition, and can be debilitating.

There are many great treatments available, but here are just a few solutions for osteoarthritic foot pain that you can try prior to seeing us at the Family Foot and Leg Center:

1.      See me at least once a year to monitor changes, and modify treatment
2.      Comfortable and supportive shoes are necessary, and sometimes orthotics or ankle braces are also helpful
3.      Weight loss
4.      Anti-inflammatory medications such as NSAIDS (ibuprofen) or corticosteroid injections that can be given by your podiatrist
5.      Physical therapy and exercises
6.      Try a topical medication that has capsaicin, an ingredient that can help reduce pain

Dr Brian Timm
Board Certified by American Board of Podiatric Surgery

Masses on your foot

There are many types of tumors that affect the foot, and many are benign.    

Two of the most common types are ganglion cysts and plantar fibromas.  

Ganglion cysts are also known as bible cysts because common treatment was hitting them with a bible so that the cyst would burst.  Ganglion cysts are more common in younger people, while plantar fibromas are more common in older people.  

Ganglion cysts often occur on the top of the foot, but are also very common on the hand.  The cysts are fluid-filled, occur at joints, and often change size. Ganglion cysts are usually observed for any changes unless they reach a size that causes pain or pressure on nerves or arteries.   Immobilization of the area is also sometimes helpful because activity often causes the cyst to increase in size.  If they reach a large size, then further treatment may be beneficial.  Further treatment of ganglion cysts usually consists of draining the fluid with a needle, or aspiration.  Aspiration of the fluid is not always successful because the root of the cyst may remain, and the cyst will return.  Surgical treatment may be recommended for recurring ganglion cysts. 

Plantar fibromatosis is the most common benign tumor on the bottom of the foot.  Plantar fibromatosis is also known as Ledderhose’s disease, which is a thickening of the foot’s plantar fascia.  Over time the lump increases in size, and may start causing pain or limitations in activity.  This type of benign tumor is often associated with a family history of the disease, or patients with diabetes.  Initial treatment is off-loading to avoid direct pressure or worsening of the tumor.  Corticosteroid injections and cryotherapy are often used initially before surgical options are considered.  Surgical removal of a plantar fibroma is more difficult than removing a ganglion cyst, which is why more conservative therapy is recommended unless conservative methods have failed. 

Ganglion cysts and plantar fibromatosis are only two of many types of possible tumors, but they are the most common benign tumors presenting in the foot.  These are both very manageable conditions, but with any lump or bump in the foot it is important to see your Podiatrist to rule out something more serious.

Brian Timm, DPM, FACFAS

Diplomate: American Board of Podiatric Surgery

Board Certified in Foot Surgery

Blister Protocols

Blisters are caused by skin friction. Your foot is sliding or shifting in your shoe during running and other activities. Fluid collects between the irritated layers of skin tissue and swells. Blister treatment should help to avoid infection, minimize pain and discomfort, stop swelling and maximize recovery.  

Most of the time patients are not presenting in the office with this as a chief complaint unless it is infected or not healing readily, but patients often ask me how to treat them. Here is a good guide in general for you to follow, keep in mind this does not include DIABETICS, as you all should not treat your own wounds without my help.

Brian Timm, DPM, FACFAS

Diplomate American Board of Podiatric Surgery 

For an​​ intact blister:

• Apply a piece of moleskin, adhesive felt or tape that is 1.5 to 3.25 inches larger than the blister, with a central hole slightly larger than the blister
• .Apply antibiotic ointment.
• Place a piece of gauze over the moleskin, felt or tape and add a piece of adhesive tape to hold the gauze in place.

Over-the-counter products such as Mueller® More Skin or Spenco® 2nd Skin® work well for blister relief and protection.

If you are going to continue running, drain blisters in weight-bearing areas that are greater than 0.8-inch in diameter. Follow these steps:

1. ​​Clean the site with an alcohol wipe or hydrogen peroxide.
2. Use a flame sterilized needle to lance two to four holes in the side of the blister.
3. Apply pressure to push out the fluid. Clean and dry the skin.
4. Apply benzoin around the blister. 
5. Apply a thin layer of antibiotic ointment at the puncture sites. Do not remove the outer layer of dead skin.
6. Apply a blister care product. 
7. Check the site daily.

If the fluid appears hazy or cloudy in the blister, drain it. Apply antibiotic ointment and a protective covering. Check the site frequently.

For a r​uptured blister:

1. Treat with antibiotic ointment over the blister and use a protective covering. 
2. If the outer layer is torn off or only a flap is left, carefully cut off the loose skin, clean the area and cover the new skin with antibiotic ointment. Use a protective covering such as Tegaderm, or some other variant over the counter. 
3. If infection is present, clean the site frequently, apply antibiotic ointment and see your health care provider for more treatment options.

Credentials you can trust.

Often times patients will ask me what my credentials actually mean. Below is a summary directly from the website of the American Board of Podiatric Surgery (which will change the name to American Board of Foot and Ankle Surgery this year) which delineates the prerequisites necessary to be deemed "Board Certified" by this particular surgical board. 

-Dr Timm

Diplomate American Board of Podiatric Surgery

Certification in Foot Surgery

Certification in Foot Surgery              indicates that a podiatrist has demonstrated a cognitive knowledge of podiatric surgery, including the diagnosis of general medical problems and surgical management of foot diseases, deformities, and/or trauma, and those structures which affect the foot and ankle.                                                       THE CURRENT QUALIFICATIONS INCLUDE:                                           

Completion of a four-year doctoral training at a CPME-accredited podiatric medical school.                         

Completion of residency training program approved by the Council on Podiatric Medical Education (CPME).                                                                                                                                                                            

Submission of a list of procedures through Podiatry Logging Service for Surgery demonstrating a diversity of surgical experience in foot surgery.    

Approval by the ABPS Credentials Committee of complete foot surgery case documentation of procedures selected by ABPS from the list of procedures.       

Passing Part I and Part II of the Certification in Foot Surgery Examination.Diplomates certified in Foot Surgery must recertify every ten years.

Do your toes have a mind of their own?

Question and Answer forum on Hammer Toes

We are performing most of these corrections in office with a variety of techniques which may not even require hardware. Depending on the severity of the symptoms and the extent of deformity we can successfully implement a sound strategy to reduce or eliminate the deformity and allow for quick return to shoes/activity.

Brian Timm, DPM, FACFAS

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 anesthetic (be asleep)?Not if you did not want one. Many of these procedures are performed perfectly safely under local anesthetic (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

What you need to know about your health.

It is our commitment to our patients that drives us to become one of the leaders in helping prevent healing complications post operatively, prevent bacterial infections and viruses, and even enhance wellness without any adverse complications. Our way to do this is through an innovative technology as a distributor for MonaVie health products in our offices.

- Dr Timm

You are not allowing your body to optimally function, which can lead to increased risk of heart disease, reduced memory capacity, and even hypertension. Here's how you can change this and allow yourself to increase vigor, health, and vitality.

Scientific Overview

NATURE’S SCIENCE UNLOCKED

Dedicated to unlocking, sharing, and protecting the earth’s most unique, health-giving resources, MonaVie combines science and nature to bring you the highest quality products possible.

• Draw upon millions of dollars in clinical research
• Supported by more than 60 independent scientific studies
• 10 published studies in national peer reviewed journals
• 4 U.S. patents

YOUR HEALTH, OUR COMMITMENT

MonaVie’s dedication to your overall health extends far beyond the first sip. Combining the best of science and nature, we draw on millions of dollars of clinical research and more than 50 scientific studies—including eight published in national peer reviewed journals—to develop our premium health products.

By unlocking, sharing, and protecting the most valuable resources our planet has to offer, we are able to deliver powerful health-giving benefits in every bottle. Our rigorous testing standards ensure the highest possible quality products and demonstrate our commitment to science and—most importantly—your health.

 

SCIENCE ESSENTIALS

While it is essential to life, oxygen can also have a detrimental effect on your health. As your body’s cells use oxygen to create energy, they also create a potentially damaging byproduct called free radicals.

 

WHAT ARE FREE RADICALS?

Free radicals are organic atoms or molecules that have an unpaired electron in their outer cellular ring. Since electrons have a tendency to exist in pairs, free radicals become unstable and latch on to electrons from other atoms and molecules in your body. This cycle creates a biological chain reaction that can damage cell membranes, accelerate the aging process, and contribute to certain ailments. Stress, lack of sleep, a poor diet, UV radiation, exercise, and pollution can all contribute to the formation of free radicals.

These unstable atoms can lead to a physiological imbalance in your body called oxidative stress. When this occurs, your body is unable to counter the damaging effects caused by these rogue molecules. This can be demonstrated by cutting an apple in half. As the fruit is exposed to air, it starts to turn brown. On a cellular level, the oxygen in the air is interacting with the cell wall of the apple’s tissues, creating free radicals.

 

WHAT ARE ANTIOXIDANTS?

Antioxidants are molecules capable of preventing free radicals from damaging healthy, functioning cells. By donating an electron to these unstable molecules, antioxidants help terminate this chain reaction before crucial damage occurs. Though your body inherently creates some antioxidants, these life-protecting phytonutrients are generally found in richly pigmented fruits and vegetables. While thousands of antioxidants are found in nature, polyphenols and flavonoids (a class of polyphenols) are two of the most effective.

 

WHAT ARE POLYPHENOLS?

Polyphenols are natural chemicals responsible for the color, flavor, and scent in fruits and vegetables. Deeply pigmented berries such as açai are especially high in these antioxidant compounds. Found mostly in the outer layer of fruits, polyphenols offer protection from harmful bacteria and ultraviolet light. In humans, polyphenols protect your body from oxidative damage and support cardiovascular health.

 

POWERFUL NUTRIENTS FIGHT AGAINST AGING

The MonaVie premier juice blends contain powerful nutrients that aid your body in the fight against aging and other symptoms of oxidative stress. In fact, just four ounces provide you with the antioxidant capacity of approximately 13 servings of common fruits and vegetables.