Holiday Foot Care Reminders

With the holidays fast approaching, many individuals may feel the mounting pressure of finding the perfect gift by spending hours at the mall.  The pressure placed on feet dashing from store to store can add up, and in individuals with diabetes can become dangerous.   Even though the holiday of St. Nicholas passed this past week, in which children leave their shoes out to be filled with treats, individuals with diabetes may still want to leave their old shoes out for good and opt for a better, pressure relieving pair.  

High pressure in a healthy foot signals pain, and subsequent alleviation of the inciting pressure by the person moving their foot or changing their shoe to stop the pain from occurring.  In diabetic individuals with peripheral neuropathy, pain and areas of high pressure cannot be felt due to loss of sensation.  This loss of sensation causes of loss of protection to the foot and wounds may develop in areas of abnormally high pressure.  Any deformity that predisposes the foot to rub in a shoe creates an area that is more likely to ulcerate.  Surgery to remove deformities including bunions, hammer toes and bony bumps in the ball of the foot are one of the ways that your podiatrist may remove an area of increased pressure that is likely to develop or has previously developed an ulcer.  Surgery to lengthen the tendon that attaches the calf muscles to the heel bone is also used to lessen pressure on the ball of the foot.  When this tendon is too tight, the heel is lifted and the front of the foot is levered down towards the ground, creating an area of high pressure. 

Along with surgery, regular callus and corn removal by your podiatrist is also very helpful in removing pressure.  Shoes, casting and custom orthotics are all used to better disperse pressure on the foot.  These treatment means are also useful to prevent ulcers from developing or recurring.  By custom molding shoes to the foot, deformities are accommodated for and areas of high pressure are relieved.  Custom orthotics for diabetic patients with neuropathy are made with several layers of material so that any friction that would normally be imparted to the foot is instead absorbed by the orthotic.  Talk to your podiatrist about taking pressure off this holiday season and keeping your feet healthy!

Brian Timm, DPM, FACFAS

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.

Diabetics who smoke cigarettes beware

Smoking releases a molecule known as norepinephrine, which triggers blood vessels to constrict, or narrow. When the already small vessels in the foot constrict, oxygen and the cells that fight infection and aid in healing are unable to reach tissues. Each cigarette smoked has been shown to cause oxygen levels to fall and remain low for 30 to 50 minutes. This is of great concern in those with a foot wound or incision after surgery, in which blood flow and oxygen are vital to skin healing.    

Each cigarette contains more than 4,000 natural and synthetic chemicals. Some of these chemicals include carbon monoxide, methanol (which is found in rocket fuel), ammonia, and nicotine.  Nicotine has been shown to decrease the molecules that are responsible for growth of new blood vessels and development of osteoblasts, or bone building cells. Carbon monoxide further contributes to the decrease in tissue oxygen caused by vessel constriction, by taking oxygen away from the molecule it is normally transported in in the blood. It is for these reasons that quitting smoking is imperative for individuals with foot problems. Studies have shown that there is a 2.7 times higher risk of bone not healing in smokers compared to non-smokers undergoing foot surgery.  

Prior to foot surgery involving bone, smoking should be stopped at least 6 weeks prior to the procedure if possible and then take that opportunity to stop smoking indefinitely. 

In individuals with diabetes or other disorders affecting their blood vessels, smoking is even more dangerous.  Pressure ulcers develop when sensation is diminished and the normal feeling of pain associated with a wound is not present. Tissue healing is impaired and there is a heightened risk of infection developing. Combined with smoking, such risks are furthered increased. Individuals with diabetes who notice a foot wound, whether they are smokers or not, should contact their podiatrist immediately. Early treatment can prevent infection and worsening of the wound that can potentially lead to a need for amputation.  Bill’s story in the smoking ad is a scary one, but by sharing it he may be able to prevent others from suffering a similar fate of amputation. 

The Lover's Fracture

The calcaneus bone, or heel bone, is among the most commonly fractured tarsal bone in the foot.  Calcaneus fractures account for 1-2% of fractures in the body.  

Calcaneus fractures are also known as the Lover’s fracture.  

Calcaneal fractures often occur due to a jump from a height, which is how the term “Lover’s fracture” was coined because a lover may jump from great heights to escape from a lover’s spouse or boyfriend.

Calcaneal fractures are generally traumatic fractures occurring from motor vehicle accidents, muscular stress, or falls from a height.  We usually see these injuries in worker's injury claim cases, whereby someone has fallen off of a ladder or rooftop. 

Calcaneal fractures are categorized based on whether the fracture is displaced (greater than 2mm displacement), open (with soft tissue or bony structure exposed), closed (with skin and soft tissue intact), or comminuted (3 or more pieces).  Treatment for calcaneal fractures varies based on the type of fracture.  Standard radiographs and CT scan are used to diagnose calcaneal fractures, and determine the severity of the injury.  Pain over the heel, inability to walk, or a hematoma that extends to the sole of the foot are all signs of a calcaneal fracture.  

Presence of a hematoma on the sole is known as the “Mondor Sign”.  In a non-displaced fracture nonsurgical treatment may be sufficient.  Displaced or comminuted fractures typically require surgical treatment consisting of some type of fixation with metal plates or screws or more recently we have used multiplanar external fixation for restoration of height, the angle, and joint space of the posterior facet in the subtalar joint. 

In closed fractures surgical treatment is often postponed until swelling has subsided.  In open (exposed soft tissue or bone) or avulsion fractures (when a tendon pulls off a piece of bone), more urgent treatment is required.  Open fractures are exposed to the environment and need to be cleaned and then surgically corrected within a short time period to prevent infection which is another advantage of external fixation. 

 

Minor calcaneal fractures usually heal within a few months, and cause minimal long-term limitations.  More severe fractures may take years to heal, and never return to the previous condition.  

Long-term complications may include pain, limb length discrepancies, and changes in gait with chronic swelling, and reduced endurance and strength.  

Early treatment by the foot and ankle surgeon (ie Family Foot and Leg Center)  is the key to minimizing long-term complications. 

-Dr Timm

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.  

Innovations in Neuropathy Pain

We are performing integrated nerve blockade treatments for our patients at Family Foot and Leg Center at our East Office exclusively. 

We are currently noticing an improvement in nerve pain in the foot and ankle area, as well as some studies are finding that some patients actually have improved balance and proprioception longterm after the treatment is completed. We will see patients 2 times a week for 4 weeks, and each treatment consists of 30 minutes which combines electrical and neuroblockade consisting of lidocaine to the peripheral nerves to the ankle and foot. This treatment is revolutionizing noninvasive management of the painful condition of neuropathy. 

New Advanced Technology

The vast majority of electromedical devices available in the United States employ LF stimulation (eg, transcutaneous electrical nerve stimulation [TENS]). Balanced MF currents have been developed that produce twice the electrical current with no electrical charge. A new type of electrical current technology has been developed to enhance the stimulating lower frequencies and nonstimulating middle frequencies for increased efficacy in clinical practice. The device also combines, and simultaneously delivers, frequency-modulated (FM) and amplitude-modulated (AM) electric cell currents in the MF range. We refer to this electromedical approach as electronic signal treatment (EST).

This new technology may reach deeper into tissue structures with simultaneous modulation of amplitude and frequency between 2,500 Hz and 33,000 Hz. It is also capable of modulating its MF electric cell-signaling current down into the LF range at available frequency rates between 0.1 and 999 Hz.

In addition, we have combined the new EST with local anesthetic injections (bupivacaine 0.25%) with clinical success. This technique provides a combined (electrical and chemical) nerve block that enhances treatment of a neuropathy or a painful condition (see Tables 1 and 2). 

According to the Gould Medical Dictionary, a nerve block is defined as “[t]he interruption of the passage of impulses through a nerve, as by chemical, mechanical, or electrical means.” Because nerve blocks occur at voltage-gated channels, all nerve blocks are essentially electrical. According to Szasz, “There is no such thing as a chemical block … only an electrical block.”6 We refer to this as combined electrochemical block (CEB).

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

Cancer and your feet

We see a variety of patients from all sorts of community and word of mouth referral systems. Ultimately, patients often have far more medical issues than their feet and ankles alone. I will see various patients in different stages of oncologic management, either post chemo into radiation therapy for various malignancies, and even patients post Moh's surgery and are here for skin care of the legs and feet.  Either way, various conditions may arise post chemotherapy to manage these various cancers, and often the feet and legs can have the brunt of the side effects manifesting in various ways.  We will see patients with numbness, tingling, and even swelling in the legs after these treatments. We are called to manage these secondary conditions and have a multitude of protocols in place to achieve high levels of excellent outcomes in relief of these symptoms. Here is an overall synopsis of management of swelling of the ankles and legs:

Dr Brian Timm, DPM, FACFAS

Diplomate: American Board of Podiatric Surgery 

(Soon to be named American Board of Foot and Ankle Surgery)

Swelling

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What is swelling?

Swelling, otherwise known as edema, is a build up of fluid in the body.  Swelling most often affects the dependent extremities (like the feet, ankles and hands) but swelling can also affect other parts of the body, such as the abdomen.  Causes of swelling include:

• Fluid retention, including salt and water related to medication, heart disease, liver disease, or kidney failure.
• Blockage of veins or lymph system.
• Malnutrition.

Chemotherapy-related, or cancer swelling:

• Some chemotherapy drugs can cause fluid retention in the body.  This form of cancer swelling is most noticable in the feet, ankles, hands, and face.
• Swelling or angioedema may also occur with hives as part of an allergic reaction.  It is a vascular reaction that causes an increased ability for fluid in the cells to "leak" into the layers of the skin, resulting in swelling.  This happens much less often than hives alone.  The fluid retention causes swelling generally in the tongue, lips, or eyelids. Swelling of the airways can result in difficulty breathing, closing off of the airway and death.  If swelling is happening along with signs of breathing difficulty seek help immediately.

What are some symptoms of swelling to look for?

• Feet and lower legs get larger when you sit or walk.
• Take a look at your feet, ankles and hands.  Are they swollen?  When you press on the skin with your finger, is there an indentation that stays for a few seconds?  If so, you may have "pitting edema."
• Hands feel tight when you make a fist
• Rings are too tight
• Abdomen appears to be swelling or distended
• Shortness of breath (especially when lying down)

Things you can do to manage swelling:

• Elevate your feet as often as possible. (Either sitting in a chair with your feet on a stool with a pillow or in the bed or couch with feet up on two pillows)
• Do not stand for long periods of time.
• Avoid tight clothing (shoes, girdles, etc).
• Do not cross your legs.
• Reduce your salt intake if swelling is present. Avoid foods such as bouillon, potato chips, tomato juice, bacon, ham, canned soups, soy sauce, and table salt, for example.
• Try to eat a balanced diet (see eating well section).
• If your swelling is severe, consider wearing Jobst stockings or TED hose.
• Weigh yourself daily. Notify your doctor or health care provider if you have gained 5 pounds or more in a week.
• Take your medications exactly as prescribed.

Drugs or recommendations that may be prescribed by your doctor or health care provider for symptoms of swelling:

• Depending upon the causes of your swelling, your doctor or health care provider may prescribe a diuretic.  Diuretics - may be known as "water pills" as they work by making you urinate out extra fluid. Some examples of this medication may include furosemide (Lasix), and Hydrochlorthiazide. You may receive this medication alone or in combination with other medications.
• Your doctor or health care provider may recommend that you see a registered dietitian to help plan a diet tailored to your condition.

When to call your doctor or health care provider about swelling:

Call your doctor or health care provider immediately: 

• If you are short of breath.

Call your doctor or health care provider within 24 hours:

• If you have gained 5 pounds or more in one week.
• If you develop sudden and severe fluid retention.
• Your feet or hands feel cold to the touch.
• If you are unable to eat for more than a day.
• If you have urinated only a little bit or not at all.
• If the swelling appears to move up your arms or legs.

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.

Secrets of Chronic Achilles Pain

1) NOT all posterior heel pains are tendon problems.

We will provide a thorough examination, which includes diagnostic ultrasound, radio graphs, and clinical exam with history taking to provide the best possible outcome for your pain. There are several other structures which are present and could be treated in a different manner than any straight forward Achilles tendinitis.  Noted above, there is a bursa which is present here and can often be the root cause of pain secondary to bursitis. This is treated differently than Achilles tendinitis. This may also require MRI to determine how much of the inflammation is related to bone versus soft tissue. Additionally, and more rarely, a stress fracture can cause this pain in the calcaneus. This is not common but we check for this as well.

2) Tendon tears do NOT always require surgery.

After clinical examination and proper staging/grading of the extent of the tear, we have had success in treating Achilles partial tears and even ruptures non-surgically in select patient populations. We have a variety of techniques at our disposal in order to facilitate the healing process if surgery is not indicated. In the case of chronic tears there are several nonsurgical treatments that work, particularly PRP injections, High energy shock-wave treatments, and even physical therapy with anti inflammatory ultrasound.

3) Bone spurs are NOT always relevant. 

Often times patients will state that they "Have had a spur in the past but it went away". Usually any bone protuberance which is either palpable or visible on a plan radio-graph or MRI will NOT go away spontaneously ever and always if indicated will need resection if it is the root cause of the symptoms. In most cases the spur is not the root cause of the symptoms, and is not required to remove it, but there are far too often very large spurs which are not even symptomatic that are visible on X-ray examinations in many of our patients, therefore backing up further the concept that bone spurs are not always the real problem.

Bio-mechanically a bone spur will exist in areas of either repeated chronic trauma, or areas of chronic taut insertions. Rarely is this an isolated tumor of bone, and that being said, it is often not necessary to remove the bone spur.


Dr Timm

Board Certified by the American Board of Podiatric Surgery

Secrets of Recurring 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.

Dr Timm
Diplomate: American Board of Podiatric Surgery
Fellow: American College of Foot and Ankle Surgery