The 3 things you must know about neuromas

1) You do not NEED surgery.

At FFLC we are always finding new and improved ways to treat this painful lesion in your foot by nonsurgical measures, which are equally as effective as removing the neuroma, and without any of the side effects or risks of surgery. The best part is these modalities can be performed several times without negative consequences, and in most cases even with previous surgery performed, the treatments can be highly effective to reduce pain and improve your day to day walks.

2) After injection therapy (Sclerosing agents) you will need orthotics.

Most patients are under the assumption that once the pain is gone, orthotics are no longer necessary. This is untrue. IN fact, the need for orthotics increases, because your foot will resume previous function after the neuroma pain is gone, and this could predispose you to later recurring pain. In the proper hands, a custom molded device, or an accomodative device off the shelf can improve function in shoegear which will help the metatarsal bones stay apart so that a future nerve impingement can be much less likely to recur.

3) Radiofrequency ablation works. (NeuroTherm)

Many of our patients are presenting to our office with previous treatments attempted, such as numerous cortisone injections, previously fashioned orthosis, and even surgery. This is of no concern to us, as we have been using NeuroTherm for these very difficult cases with excellent results. We use the latest and least invasive technologies to better serve our patients, and I believe we are in the forefront of technology in this area for most foot and ankle pathology in Southwest Florida.


Dr Timm

Ankle issues for those who cannot have surgery

Not everyone is healthy enough for ankle reconstructive surgery. In fact, in Naples the average age of our patients is 65, and that can infer more often than not that some form of co morbidity exists in the summation of medical concerns which may complicate  the option to electively undergo any type of surgery. Some patients are fresh off of a myocardial infarction, others are too weak with congestive heart failure and kidney disease. The rest are very poor surgery candidates secondary to leg circulation which cannot be improved by vascular intervention. Yet this category of patient is still able to be treated for ankle and foot pains, because we can make a mold of your ankle and foot, and create a custom molded ankle/foot orthosis. This is the most common nonsurgical treatment to manage chronic pain from abnormal motion and deformity in patients who are just not candidates for any reconstructive surgery, and this allows their relatively limited mobility to be achieved with less pain and allows some patients to avoid needing a wheelchair as a primary modality of transportation. Often times, this brace will take 3-6 weeks to be available, so we offer many off the shelf intermediate bracing options for this cornerstone of patient population, as well as PRP injections and physical therapy options as well. We are not only foot and ankle surgeons at FFLC, we are also very naturalistic and have had good success with nonsurgical management of most of our patient's chief complaints regarding pain in the ankle and foot.

Different ankle concerns will require different bracing options, but we are well equipped to use whichever means are necessary to keep you walking.

New Neuropathy Treatments Available!

The Micro-Z™ and The Micro-Z MINI™ is a small, lightweight stimulator that allows patients to receive electrotherapeutic treatment in comfort. It is programmed for two treatment protocols, the first is a 30-minute daytime treatment and the second is an eight-hour nighttime treatment that is administered while the patient sleeps. The Micro-Z™ and The Micro-Z MINI™ can be used to treat acute and chronic injuries, to treat sources of pain, to increase circulation while improving range of motion, and to minimize soft tissue atrophy and injury. Its compact size and ease of use increases patient compliance and when used with Prizm's Electro-Mesh, Silver-Thera, and Stim-Support garment electrodes, they offer opportunity for rapid patient recovery.

It is estimated that nearly 75% of all amputations caused by neuropathy and poor circulation could be prevented with proper care. The National Institute of Diabetes and Digestive and Kidney Diseases recommends control of blood sugar, relief of pain (typically achieved through use of medications and or electrotherapy), and special care of the hands and feet as treatment for diabetic neuropathy. Recommended care for the feet includes frequent visual inspection, good hygiene, use of protective lubricants and wearing of special shoes. There are no commonly recommended courses of therapy that aim to both reduce pain and increase circulation in order to treat the pain associated with neuropathy and, at the same time, help reduce the risk of developing foot ulcers. PRIZM has established a clinical research program with leading specialists in the fields of endocrinology, diabetology, and podiatry at major medical universities. A pilot clinical study demonstrated benefits of the Silver-Thera™ Stocking coupled with the Micro-Z™ pulsed direct current neuromuscular stimulator in treating diabetic foot neuropathy, tissue perfusion and wound healing which resulted in a clinical publication (see research). The convenient, easy to use Micro-Z™ can be worn to bed for easy nighttime use, a factor suggested by studies as effective in alleviating subjective, burning diabetic neuropathic pain as well as dramatically increasing circulation which leads to increased tissue perfusion.

Ask one of our providers today about this new treatment, and it IS COVERED by insurance. We DO OFFER this treatment through an outside company who can get this to your home directly without more than a 7 day delay. We are always looking for improved ways to treat our patients, and this is another treatment modality which can be undertaken without any side effects.

Dr Timm

Big Toe Joint Aches and Pains - What you need to know:

Often times patients will present with what they consider to be a "Bunion" in their big toe joint, and they attribute this to their pain. Many times, this is false. A bunion is an actual deviation or dislocation of the big toe joint, whereas the painful prominence which are often gradually increasing in size after many years removed from an injury can be related or directly attributed to progressive "bump" production which has the general buzzword "Arthritis".

Arthritis is actually a misnomer, because many times the inflammation of the joint is only noted initially in the disease process and over time the cartilage wears away forming spurs and bone prominence which leads to the pain and inability to move the joint fluidly. This is actually an "arthrosis" which is the end result of the condition. Arthritis is not usually visualized directly on a radiograph but arthrosis is easily visualized.

A clinician will find effusions whenever arthritis is active. This is the "Swelling" that patients often note is painful and warrants medical attention. This is often including joint space widening in the case of inflammatory arthritis but narrowing over time with osteoarthritis, and reduction of ability to move the joint without pain and with eventual grinding.

Patients will often times not recall the traumatic event which sparks the progressive wear down of this area on their foot, but many times this is not necessary. Patients will also note that the "bunion" is growing and is usually located on top and side of the joint. This is not a bunion, as these tend to only be located on the side of the joint and not at all on top.

What do you need to know to determine what to do next??

1) If the pain is at the end of the day you should see a foot and ankle specialist.

2) If the motion of the joint is limited or not similar to your other foot, you need to see the specialist.

3) If you have been given 2 or more cortisone injections in the same joint, you need to see a specialist.


There is a common theme here. A foot and ankle specialist is paramount to help a patient achieve a good result in treating first toe joint arthrosis. Often times, this is progressive and may limit treatment options depending on the stage of the pathology. There is no actual cure for any form of arthritis, but there are means to treat and accommodate the condition in order to reduce pain and limitation with walking.  We are adept in treating all forms of arthritis, from the initial swelling stage, to the end stage limited motion in the toe joint.  There are many times several good options depending on the stage of the disease process, and we will be able to give you a definitive solution in many cases.

Dr TIMM.

Baby and Toddler Shoes

Before babies starts walking, they don't need shoes. In fact, supportive shoes like hard-soled Mary Janes may actually get in the way of your child's developing mobility. Socks, booties, and soft-soled baby shoes are useful for warmth, but bare feet are fine, too. In actuality their feet are very adaptable to the ground, whether it is carpeted or wood and tile. And early on it allows their proprioceptive feedback to allow them to balance easier and develop more readily in the very early stages without shoes.  

Once your child takes those first steps, it's time for a pair of real shoes. Unlike "baby shoes," which are more like slippers, first shoes will have a flexible, nonskid sole (probably rubber) and a more substantial upper. Shoes protect kids' feet outdoors and anywhere else that could be hazardous – a splintery surface, for example.

Note: Your child's foot is still developing, so it won't look (or act) like an adult foot. If your child still has a padding of baby fat under the arches, for example, she might appear a bit flat-footed. Or she may have a tendency to turn her toes in when she walks, called in-toeing or toeing in.Indoors (and outdoors on safe surfaces, such as sand), it's still a good idea to let new walkers wear soft baby shoes or socks. Your child can even go barefoot, if it's warm enough. Toddling around with feet bare or lightly covered actually helps little ones build strength and coordination in their legs and feet.

Mention any concerns to your child's doctor. It's easier to correct foot problems when your child is younger.

What to look for when buying

• Choose a breathable, lightweight material. Soft leather or cloth is best. Avoid stiff leather shoes, which can hinder foot development, and synthetics, which don't breathe.
• Bend the soles. They should be flexible and gripping, not smooth and stiff. A nonskid rubber sole with ridges will offer good traction.
• Check the fit. Have your child try on the shoes and stand up. There should be just enough room to squeeze your pinky between your child's heel and the heel of the shoe, and a full thumb-width between the end of your child's longest toe and the front of the shoe. The shoe should provide just enough wiggle room without being too big. Because baby feet grow quickly, it's a good idea to check every month to make sure the shoes still fit.
• Give it a squeeze. If the shoe is made of soft fabric, try to grab some of the material on the top of the foot when your child is wearing them. If you can't, the shoes might be too tight.
• Shop later in the day. Babies' feet swell and are often bigger at the end of the day. Shoes purchased in the morning might feel tight in the evening so usually try shoes on before dinner before you buy.
• Look for problem spots. Your baby's shoes shouldn't need any breaking in. Let your child toddle around indoors wearing the shoes, then take them off and look for any irritated areas on your child's foot which could be red areas or blisters, and in more rare cases even a callus formation can occur but this is not common.
• Make the choice: laces versus Velcro. Velcro fasteners make it easier to get shoes on and off, and you won't have to worry about retying laces all day. But a child may figure out how to remove his shoes and take them off when you wish he wouldn't! If you choose shoes with laces, make sure they're long enough to tie into double knots, so they won't come undone as often.

What it's going to cost you

Simple baby shoes can cost as little as $15 to $20. Fancier shoes, of course, can cost a lot more. And remember any foot concerns can be addressed at any age here at FFLC. 

DR TIMM

Flatfoot May Lead to Knee Arthritis.

DID YOU KNOW?

Having flat feet is associated with an increased prevalence of knee pain and cartilage damage in older adults according to research funded by the Arthritis Foundation. Using the Framingham Foot and OA Studies, a research team from Boston University School of Medicine and the Institute on Aging Research in Boston gathered data on 1,884  older adults whose mean age was 65 years. Twenty-two percent of knees were reported as painful on most days. Magnetic resonance images of the painful knees were acquired to determine the health of the cartilage within the joint. The Staheli Arch Index was used to determine the participants’ foot arch shape. The scientists analyzed the data and adjusted for age, sex and body mass index. 

They found that people with the lowest foot arches – commonly called “flat feet” – had 1.39 times the odds of having pain in the knee on the same leg as the low arch. Likewise, those with flat feet had 1.76 times the odds of having cartilage damage in the inner aspect of the knee joint (the medial tibiofemoral compartment). Because of the nature of the study, cause and effect cannot be determined. 

People with low or flat arches may be able to ensure proper knee alignment by wearing supportive shoes and/or orthotic inserts. 

Gross KD, et al. Planus foot morphology is associated with knee pain and cartilage damage in older adults. Abstract presented at American College of Rheumatology Annual Scientific.

Are my running shoes the right ones?

Minimalist shoes, a controversial topic in foot and ankle biomechanics and running safety.

So what is it that lets me know that a shoe like the one I wore today is the right one? I’ve tried to think about this scientifically, but sometimes subjective impressions are good enough, or even better when it comes to individual impressions. 

Here are 5 subjective things that let me know a shoe is a good match:

1. It causes no pain. 

No abrasion, no hot spots, no unusual aches in my legs or feet. No pain is good. Note: sometimes pain may be present as your body adapts to a given shoe, and it starts to feel better after a few runs, so this may not always be a perfect indicator on your first run in a shoe.

2. It disappears on my feet. 

If I weren't concentrating on how it feels, the shoe would go completely unnoticed. It doesn't make me think about my form, it doesn't force my feet to move in ways that they don’t want to, and it doesn't get in the way while I run. When I run in a shoe that’s a good match, I feel strong and as if my body is in complete control. A good shoe works with my body, not against it.

3. Ground contact simply feels “right.” 

This is something that is extremely difficult to verbalize but very easy to feel the moment I start running in a shoe that’s a good match for me - a good shoe simply feels right when it hits the ground. Unfortunately, it may require running in a lot of shoes before you get a sense of what the “right” shoe feels like for you. After you get a sense of the variation among several shoes, you begin to notice that some shoes feel dead on contact, and they feel like they rob your legs of energy. A good one feels responsive and like it’s helping you progress forward on your run.

4. It makes you want to run fast. 

Sometimes a shoe feels so good that you simply want to cut loose and run wild. It’s an incredible feeling to have everything clicking and hit that moment when you start cruising down the road or trail with reckless abandon – it’s like I imagine sitting behind the wheel of a sports car might feel (I drive a Prius…). A good shoe makes you want to move, and move fast!

5. A good shoe makes you long to run in it again. 

This, for me, is the number one sign that a shoe is a good match. When I finish a run in a good shoe, I simply can’t wait to run in it again. In fact, it may motivate me to get out the door simply so I can put it back on my feet. As I sit here writing this, I have the shoes I wore on the trails this afternoon on the floor next to me, and I have half a mind to go out for an evening run in them just to put more miles on them. On the other hand, it takes willpower to run in a shoe that just doesn't feel right to me – it’s like a wasted opportunity to get maximum enjoyment from the time I spend on the run. When you want to run in a particular shoe even though you have 50 to choose from, you know it must be a good one.