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.

Call your doctor for concerns after surgery: Morbilliform drug reaction

Morbilliform drug reaction

What is morbilliform drug reaction?

Morbilliform drug eruption is the most common drug hypersensitivity reaction. Many drugs can trigger this allergic reaction, but antibiotics are the most common group. The eruption may resemble rashes or exanthems caused by viral and bacterial infections.

It is also called maculopapular drug eruption, morbilliform exanthem and maculopapular exanthem.

Who gets it?

Morbilliform drug eruptions are very common, comprising 95% of all drug-induced skin reactions. Beta-lactam antibiotics (penicillins, cephalosporins), antibiotic sulfonamides, allopurinol, anti-epileptic drugs and nonsteroidal anti-inflammatory drugs (NSAID) are the most common drugs to cause this. However the list is very long and includes herbal and natural therapies.

On the first occasion, the skin rash usually appears 1-2 weeks after starting the drug, but sometimes may occur up to 1 week after ceasing the medication. However on re-exposure to the causative (or related) drug, skin lesions appear within 1-3 days.

In general, a morbilliform skin rash in an adult is usually due to a drug, but in a child is more likely to be viral.

The development of a morbilliform eruption after starting amoxicillin for sore throat and fever is almost diagnostic for glandular fever (infectious mononucleosis), occurring in almost 100%.

Clinical features

Morbilliform drug eruption usually first appears on the trunk and then spreads to the limbs and neck in a symmetrical pattern. Mucous membranes are not affected.

The exanthem consists of widespread pink-to-red flat spots (macules) or raised bumps (papules) that blanch with pressure. It may resemble the rash of measles, rubella or scarlet fever, thus mimicking viral and bacterial exanthems. The spots may cluster and merge to form sheets over several days, sometimes involving the entire skin surface. On the lower legs the spots may appear purple and non-blanchable (purpura), especially if the patient has a low platelet count. On the extremities the spots may appear ring-shaped (annular) or hive-like (urticaria-like), giving a polymorphous (mixed) appearance, a clue that this is a drug reaction and not due to infection.

The rash may be associated with a mild fever and itch.

Treatment

Often times patients can develop this presentation with use of prophylactic antibiotics, and the best course of action is to discontinue the medication if possible immediately. Other times ancillary treatment may also be useful such as prednisone, cremes, diphenhydramine, and referral to allergist for severe cases.  

Pickle-Ball tips for Seniors

1. Don’t red line your heart by working out to exhaustion.
   
2. Use lower intensity, endurance-type exercise such as bicycling, swimming and jogging slowly as cross training.  Cross training is what makes you stronger and more fit.   More pickleball just gives you overuse syndrome.
   
3. Drill on the pickleball court part of the time and play part of the time.
   
4. Sit down and rest when you get tired.
   
5. Nap if possible.
   
6. Eat healthy foods like green leafy vegetables, fresh veggies, fresh fruit not juice.  Leave out carbs with white sugar.  A banana, low fat yogurt and a bagel for breakfast is not a balanced healthy way to hit the pickleball court.  Why not? Any low fat product has more sugar in it (not more calories, but more sugar).  A banana converts to sugar and a bagel is starch (which converts to sugar).   Put a little almond butter and banana on the bagel or tuna on the bagel for some added protein.
7. Stretch after you exercise.  Stretch all the time.   Stretching even a little goes a long way for your health.
   

Hope this helps,

Dr Timm

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