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.

Rollerblading and your ankle health.

Although rollerblading is a low-impact sport, The Consumer Product Safety Commission reported an average of over 32,000 inline skating injuries every year from 2003 to 2007, according to the National Safety Council. Most injuries affect the upper body, but ankle injuries are one of the most common injuries to the lower extremities.The firm boot of an inline skate provides good ankle support when the skate fits properly, but fit is key. Protecting your ankles means not just following proper skating technique but also shopping smartly for your inline skates.

Often times the ankle will be supported well within the confines of the device. However knee sprains and syndesmotic injury can occur (high ankle sprain) in the right setting while rollerblading. More often foot injury is likely, with blisters, metatarsalgia, and even mild neuropraxia in the wrong rollerblade configuration. This is a general guide to choose the right blades for your feet.

Dr Timm

Diplomate American Board of Podiatric Surgery

Selecting Skates

Step 1

Shop for skates after a day of activity to compensate for any swelling of the feet that occur while rollerblading.

Step 2

Pick skates for your gender, especially if you are a woman. While women can wear unisex skates, those designed especially for a woman better fit a woman’s narrower Achilles tendon and lower position of the calf muscle, notes Liz Miller, author of “Beginner's Guide to Inline Skating.”

Step 3

Look for skates that lace up and buckle at the top. The combination provides a more secure fit for ankle support.

Step 4

Squeeze the plastic support in the boot. It should be firm and unmovable.

Step 5

Try on skates wearing a pair of thick, absorbent athletic socks -- the same type of socks you’ll wear when skating.

Step 6

Wear the skates for at least 15 minutes before making a purchase. When laced and buckled, the skates should feel snug, but not so tight that any part of your foot feels pressure.

Skating

Step 1

Stretch before skating. To prevent ankle injuries, focus on your feet: Flex and point your toes and rotate your ankles in circles.

Step 2

Kick your feet into the back of your rollerblades before lacing and buckling up.

Step 3

Warm up by gently skating around for five minutes.

Step 4

Match your skating location to your skating ability. If you are a new skater, begin on a large patch of level grass. Empty tennis courts and parking lots are also good places to learn.

Step 5

Bend your knees when you skate to lower your center of gravity. Skate with a wide stance if you are new to the sport. Skate with a shoulder-width stance if you are an experienced skater. A narrower stance gives you better control for tricks, but a wide stance helps beginners maintain balance.

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.

Myths about wound care

1) Wound Care Centers are the gold standard for healing all wounds.

All too often we see a wound such as the one pictured above, and as a second or third opinion we need to manage this patient because the wound is not healing. Wound care centers are usually very good at treating superficial wounds, but in the foot and especially in the area of the digits, we find that even a "small superficial dry ulceration of the hallux" can be a surgical emergency because of the proximity of bone and tendon in this area and are often not treated entirely well in a wound care center which is filled with nonsurgical wound care doctors. 

2) Diabetics don't heal well.

This is not always the case in a patient who has a dopplar examination of the lower extremities, and is found to not have any significant vascular disease. If you are eating 3 meals a day, and are not on dialysis chances are you have healing potential and just need better offloading, aggressive surgical debridement, and possibly a localized bone debridement or tendon procedure. We often team up with vascular surgeons, infectious disease doctors, and endocrinology doctors to help achieve optimal conditions to prevent amputations. 

If your foot and ankle wounds are not improved after 4 weeks of care, you need to see a wound care specialist board certified in foot and ankle surgery.



Brian Timm, DPM, FACFAS

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

PRP Literature Review

As the use of PRP increases, additional studies may establish PRP as an efficacious treatment modality and guide future treatment of chronic diabetic foot ulceration.

- Yale Journal of Biology and Medicine March 2010



We have been using PRP injections in this manner since 2010 as well, and this study was published promptly (and independently) from our center, but it shows the progressive mindset and improved outcomes from our center.

We are always striving to obtain the latest in technology to help treat our patients both effectively and not only by use of standard of care methods we will often go ABOVE the standard of care to ensure the most optimal in outcomes for our patients with diabetic wounds and neuropathic ulcerations.


McAleer et al. (2006) found that the use of autologous PRP was successful in healing a chronic lower extremity wound in a case study of a 57-year-old man with type 2 diabetes and a wound of six months duration. 


Salemi et al. (2008) was a more recent case study evaluating the effectiveness of a combination of autologous adipose tissue and PRP in a lower extremity ulcer of three years duration in a non-diabetic 65-year-old male patient.

Margolis et al. (2001) was a retrospective cohort study devised to estimate the effectiveness of platelet releasate (PR) in the treatment of diabetic neuropathic foot ulcers. Of the 26,599 patients included in the study, 21 percent were treated with PR by the end of the 12-week run-in period before the 20-week study period began.  The investigators concluded that PR was more likely to be used in more severe wounds and was also more effective in treating these wounds than the standard of care. 

Driver et al. (2006) carried out the first reported prospective, randomized, controlled multicenter trial in the United States regarding the use of autologous PRP for the treatment of diabetic foot ulcers. Participants included 72 patients with type 1 and type 2 diabetes between the ages of 18 and 95 from 14 investigation sites suffering from an ulcer of at least four weeks duration. In this study, investigators compared the effectiveness of autologous PRP gel to that of normal saline gel for 12 weeks. The primary objective of this study was to evaluate the safety of PRP and the incidence of complete wound closure, defined as 100 percent re-epithelialization, when compared to the control treatment, and a secondary objective was rate of wound closure. Patients were randomized into two groups — standard of care with PRP gel or control (saline gel) — and were evaluated biweekly for 12 weeks. After excluding 32 patients from the final per-protocol analysis because of failure to complete treatment and protocol violations, the authors found that 68.4 percent (13/19) of patients in the PRP group and 42.9 percent (9/21) in the control group had wounds that healed. Wounds in the PRP group healed after a mean of 42.9 days (SD 18.3) vs. 47.4 days (SD 22.0) in the control group. 

This is significant, because the longer the duration of time that there is an ulceration on the plantar skin the more directly proportional to likelihood of osteomyelitis formation occurs. 


Metalink: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2844688/