Foreign bodies made in America

Most foreign bodies we see in our center are not incredibly too foreign. In fact, most of these objects tend to be naturally occurring debris from the oceans and lakes in Florida. Shells, stingray barbs, and even an occasional brackish water stone laceration to the plantar foot. If these injuries are not treated  in emergent fashion, this may lead to subsequent infection.  In the case above, this patient was running in a bonfire for some odd reason, and apparently one of the sharper wooden shards punctured the foot and simultaneously burned it, leaving him with second degree deep tissue burns. This was not immediately treated until 3 days later, and he ended up needing surgery to clean the wound and remove dead tissue within the area. He also requires IV antibiotics and several weeks of protected weight to the area with crutches until it all heals. We will see this during the "seasonal time" here mainly because more vacationing residents will be on the beaches, or wherever and they will not wear shoes. A foot injury like this is usually easily prevented just by wearing a sandal or sneaker at all times while outside. Most times, our feet are not well equipped to deal with the amount of sharp and dangerous objects that may lie waiting for unsuspecting tourists to walk on them. If you suspect you have stepped on something, don't wait. Come to see us at the FFLC, so we may rapidly diagnose, treat, and remove any foreign object from the foot before infection and need for hospitalization may occur. We can remove the foreign object right in office, and are well equipped to obtain cultures from the area, perform ultrasound guided removals, and even identify radio opaque material with use of radiography.

Green Bay Packers season in peril on account of a foot injury

The season looks dire so far in 2012 for any Green Bay fan, as first we lost a game on a call which was undoubtebly the most controversial and ridiculous call in NFL history to the Seahawks and now we lose to the Colts with a rookie quarterback and with that we also lose 3 more starters on both sides of the ball due to significant injuries. Not to mention that both the Bears and Vikings are winning every week now. We were 15-1 last year, and this year we probably will not make the playoffs as we are already 3rd place and have a 2 game deficit to both teams ahead of us with the Texans coming up next week who will likely demolish the Packers.

After losing to the otherwise rebuilding Colts, another unfortunate injury may have been partly responsible. The Packers have had a mediocre running game as it is this year with Benson, but now we have to struggle further without him. Maybe there is a good practice squad runner that nobody knows yet who can step it up and have a "next man up" mentality a la 2 years ago with our playoff run with an unknown running back. To make things even worse, with the loss of Cedric Benson, a running back who was supposed to be main addition to an offense that has had little trouble scoring points through the air last season, and give this team another dimension to confuse defenses and give Aaron Rodgers some help with the ground game, his ability to cut and balance and jump may have been permanently altered because of his foot injury. Teams will sit in zone defense and blitz packages knowing fully that we have no ground game to use and this will be a long year for certain.

Now, not only can we not pass the ball very consistently because the offensive line cannot block anyone, but we really will be left unable to run the ball as well, and Rodgers will continue to get sacked 5 or more times a game and potentially sustain another concussion, and we have nobody on reserve as a quarterback, because we let him go to Seattle in the offseason!! Fire Dom Capers too, because our defense cannot hold a three score lead against the COLTS!!

Anyhow...

Benson has suffered a midfoot sprain. This injury has been relatively common this year, with both Benson, and Santonio Holmes of the Jets suffering this injury already this year. Last year the Texans had a quarterback who also had a Lisfranc injury.
A most devastating injury, which can sideline a player for 2 months, and may lead to longterm pain and need for fusion if arthrosis and degenerative joint disease ensues. Football requires quick changes in direction, jumping, and running with quick stops and starts. All of these motions are difficult when a player has sustained such an injury. Longterm, we have noticed a number of patients who have likely had such an injury in the past and was not diagnosed or treated properly and are left with a change in the position and alignnment of the midfoot. This may lead to rockerbottom foot deformity in extreme cases, and most likely will lead to chronic recalcitrant pain in many cases. Ideally the bones should be reduced as soon as possible in cases of initial instability to their anatomic position, but this is often times not done on account of lacking evidence of fractures, or poorly obtained radiographs which do not show the alignment concerns from this injury secondary to the patient being unable to stand on the foot in order for the films to demonstrate the instability. Regardless, once the swelling has diminished with non weight bearing and casting, a flat film with the patient standing should be obtained to see if any instability has occured, otherwise the patient may be placed under anesthesia in order to use an active xray machine to stress the midfoot in order to demonstrate any need for fixation.

Turf the "Turf Toe" Injury

Often around this time of the year, football injuries become more prevelant in our practice with high school and junior leagues. The great toe will get hyper-extended for a brief moment, and this leads to pain and inability to return to sport. Sometimes this injury can lead to chronic instability of the toe joint which may lead to arthritis and eventual need for surgery if not treated properly with initial presentation. This injury is typically treated incorrectly with coritsone injections, and this may actually lead to further damage to the joint capsule and even the ligament between the sesamoid bones. Treatment for this condition starts with proper evaluation, detailed history and physical examination, and sometimes with foot blockade of local anesthetic or even arthrogram, we can diagnose and give a prognosis to return to the field in 1 visit. This treatment may consist of casting, immobilization, PRP injections, or even surgery for progressively more unstable joints or specific findings from MRI examination. Ultimately, athletes can expect a minimum of 2 weeks off, followed by gentle passive range of motion exercises, and finally we may allow return to the field for practice and eventual playing time. Most athletes will not return to the field if they are unable to dorsiflex the great toe joint at least 50 degrees without pain. If a patient has progressive deviation or valgus deformity becomes evident, surgery is most likely indicated. If the pain improves after proper immobilization and therapy driven rehabilitation, many will not require surgery.  Ultimately it is decided based on timely diagnosis, treatment, and therapy driven rehabilitation. Notable players who have had Turf Toe injury include Deion Sanders and Ray Lewis. Sometimes this injury will end the professional player's career.

Stem Cells and Placental Growth Factors

Often times, new technology is encountered in any medical subspecialty that raises eyebrows and concerns patients. This is usually met with skepticism and may even offer need for second opinions depending on the nature of the treatment in question.  This practice is always striving to be on the cutting edge of new technology and we have always tried to offer all nonsurgical management options possible depending on the clinical pathology at hand. We see many patients each day with chronic tendon tears, or capsular injuries which are subtle, and most often longstanding. These sorts of injuries range from mild symptoms, to severe tendon pathologic weakness. Often times these injuries and chronic conditions would require bracing and surgery, but more biotechnology is becoming available with new data suggesting alternatives to these sorts of treatments. There are several companies which are bringing cellular technology that contains growth factors such as PDGT A and B, FGF, TGF-beta, EGF, and various others with stem cell progenitors which may lead to proliferating tissues in vitro.  This is exciting, primarily for patients who otherwise are told they need extensive tendon debridement and reinforcements, otherwise they require extensive bracing and immobilization which will limit activity level and lead to further health issues longterm.  This technology may not heal a tendon which is 80% torn, or increase range of motion in a great toe joint with capsular damage that has led to cartilage compromise, but it may be the sort of technologic treatment to serve as another intermediate step in the progressive nature of treating chronic foot and ankle tendonopathys and capsulopathies which may prolong or negate the time frame to need any sort of surgery.  Data is still being amassed and certainly no final consensus has been reached as to how much these sorts of injectable treatments can benefit patients in differing tendon dysfunctions, but one thing is certain: FFLC will be there to at least help evaluate these treatments and offer all beneficial treatments possible to our patients.

DR TIMM

NFL reciever Nicks may return to line up tonight.

One of the more prolific pass catchers for the NFL New York Football Giants will return to his number 88 jersey possibly tonight after recovering from his fifth metatarsal fracture ORIF surgery from May 2012. He likely had a Jones fracture, which in most cases with athletic players a percutaneous screw was utilized in order to fascilitate healing. At FFLC, you are not required to be an NFL player to get this state of the art procedure if necessary, as we have successfully treated numerous athletic patients with this traumatic injury using this specific technique with minimal to no complications.

The main reason why surgery is likely required in these individuals with the fractured fifth metatarsal, stems from the nature of the amount of weight applied to the area with each step, as well as where the tendons insert at the most proximal aspect of the main fracture fragment, with each step the tendon pulls away this fracture from the main portion of the bone.  Sometimes a below knee cast is applied to stop all motion, but even this may not fully accelerate healing. The screw fixation eliminates all motion to the site, and by placing the screw, the surgeon is able to drill through the scar tissue and promote healing with placement of demineralized bone matrix proteins and collagen to enhance liklihood of healing the fracture.

So if you happen to catch the Patriots and Giants tonight, keep your eyes on number 88, as his cutting and route running is still going to be at a high level after his injury, because he had state of the art surgery in order to heal his fracture.

Chemotherapy and your feet.

Some of our patients are undergoing chemotherapy to treat various cancers, and this may cause some patients to experience painful scaling skin on the palms and soles of their feet and hands. Here is some general information to guide you towards improving this condition. Please come and see me if any problems or concerns arrise.

- Dr Timm

Hand-Foot SyndromeOther terms: Palmar-Plantar Erythrodysesthesia; PPE What is hand-foot syndrome?Also called hand-foot syndrome or hand-to-foot syndrome, Palmar-Plantar Erythrodysesthesia is a side effect, which can occur with several types of chemotherapy or biologic therapy drugs used to treat cancer. For example, Capecitabine (Xeloda^{®), 5-Flurouracil (5FU), continuous-infusion doxorubicin, doxorubicin liposomal (Doxil®), and high-dose Interleukin-2 can cause this skin reaction for some patients. Following administration of chemotherapy, small amounts of drug leak out of very small blood vessels called capillaries in the palms of the hands and soles of the feet. Exposure of your hands and feet to heat as well as friction on your palms and soles increases the amount of drug in the capillaries and increases the amount of drug leakage. This leakage of drug results in redness, tenderness, and possibly peeling of the palms and soles. The redness, also known as palmar-plantar erythema, looks like sunburn. The areas affected can become dry and peel, with numbness or tingling developing. Hand-foot syndrome can be uncomfortable and can interfere with your ability to carry out normal activities.}
Things you can do if you suspect hand-foot syndrome (Palmar-Plantar Erythrodysesthesia):
Prevention: Prevention is very important in trying to reduce the development of hand-foot syndrome. Actions taken to prevent hand-foot syndrome will help reduce the severity of symptoms should they develop.This involves modifying some of your normal daily activities to reduce friction and heat exposure to your hands and feet for a period of time following treatment (approximately one week after IV medication, much as possible during the time you are taking oral (by mouth) medication such as capcitabine). Avoid long exposure of hands and feet to hot water such as washing dishes, long showers, or tub baths. Short showers in tepid water will reduce exposure of the soles of your feet to the drug. Dishwashing gloves should not be worn, as the rubber will hold heat against your palms. Avoid increased pressure on the soles of the feet or palms of hands. No jogging, aerobics, power walking, jumping - avoid long days of walking. You should also avoid using garden tools, household tools such as screwdrivers, and other tasks where you are squeezing your hand on a hard surface. Using knives to chop food may also cause excessive pressure and friction on your palms. 　Cooling procedures:
Cold may provide temporary relief for pain and tenderness caused by hand-foot syndrome.
Placing the palms or bottoms of your feet on an ice pack or a bag of frozen peas may be very comforting. Alternate on and off for 15-20 minutes at a time.
Lotions:
Rubbing lotion on your palms and soles should be avoided during the same period, although keeping these areas moist is very important between treatments.
Emollients such as AMLACTIN, Aluvea,Aveeno®, Lubriderm®, Udder Cream®, and Bag Balm® provide excellent moisturizing to your hands and feet.
Pain relief:
Over the counter pain relievers such as acetaminophen (Tylenol®) may be helpful to relieve discomfort associated with hand-foot syndrome. Check with your doctor.
Vitamins:
Taking Vitamin B6 (pyridoxine) may be beneficial to preventing and treating Plantar-Palmar Erythrodysesthesia, and should be discussed with your doctor.
Drugs/treatment changes that may be prescribed by your doctor:
Chemotherapy treatments may need to be interrupted or the dose adjusted to prevent worsening of hand-foot syndrome.
When to call your doctor or health care professional:
If you notice that your palms or soles become red or tender. This most often occurs before any peeling, and recommendations for relief of discomfort can be given. If you are on chemotherapy pills, you may be asked to hold treatment, or need your dose adjusted to prevent worsening of symptoms.

Pain in the Achilles !!

So many of our patients suffer from what we in the medical field call "Tendonopathy". This is a vague term which encompasses a vast array of varying pathologic conditions, in both acute and chronic presentations.

Probably one of the main contributers to the more common tendonopathy that we see is the pressence of a large spur behind the heel which is associated near the insertion of the most important tendons in the foot and ankle - ie the Achilles tendon.

Numerous treatments in the literature have been described, and the main thing to consider in these situations, is that there are viable nonsurgical options available for this disorder. Many patients hesitate to present in the office of a physician with lumps and bumps on their extremities for fear of needing surgery. This is a problem, because most of the time these anxieties allow the pathologic process to worsen, and eventually by delaying treatment you are nearly obligating yourself to undergo the one treatment you were trying to avoid.  Surgery is always a last option for posterior heel pain, as this can require 3 months or more to recover from depending on the nature of the pathology and extent of procedures required to rectify the conditions. Many times, we can identify the extent of the pathology and at least rule out tearing or masses with the use of ultrasound technology which is readily available in the office. Often, we require MRI images to plan should nonsurgical options fail to reduce symptoms.

We offer state of the art high energy shock wave therapy coupled with PRP injections to the posterior achilles for pain and thickening, and to reduce symptoms from protruding and prominent boney areas behind the heel that may be penetrating through the tendon in this part of the foot, thus causing tendonopathy pain. This treatment is more effective in less chronic cases, but is usually able to reduce the pain and edema from these conditions in most cases. Shoegear choices are also a factor here, as many ill fitting shoes may contribute to pain in areas of boney prominences.

Do not hesitate to make an appointment, as we may be able to reduce your pain without surgery !