3 Myths about Ingrown Nails:

1) Ingrown nails can be treated with a PEDICURE.

As the image above shows, some patients will develop a deformity of the edge of the nail which extends underneath the skin and leads to pain and puncture of the skin eventually leads to infection. A pedicure only treats the exposed nail, and they are generally not able to relieve the symptoms entirely because of sensitivity to the area. In most cases, it is required to use local anesthetic to completely allow access to this painful area and this can only be accomplished in the office of a trained medical professional.



2) Ingrown nail surgery is painful.
It is actually more painful to allow this infection to become what is shown by the clinical picture above. This sort of infection is more painful secondary to the pressure from the underlying purulence, and pressure from the nail tissue pressing into the surrounding skin. After your procedure is completed, you will leave the office in no pain and after the lidocaine wears off, the pressure and sharp pains you were experiencing prior to the intervention will be minimal, and in most cases can be relieved by over the counter Alleve medication or variant.




3) After nail surgery my nail will be narrow

This is immediately after the nail is removed post procedure. The reddened area is raw tissue which is exposed post partial matrixectomy and prior to the chemical cauterization. As you can see, the nail that is visible is very normal looking, and most of the nail which is removed is not usually visualized as it is beneath the skin layer.


After several weeks, the nail tissue will heal, and the new nail border will attach to the side and appear very natural. In this clinical example it is the same procedure just a few weeks after, and the area that looks like a deficit in skin will fill in over time and the new nail fold will attach without any further intervention.


Brian Timm, DPM, FACFAS
Diplomate American Board of Podiatric Surgery 

My Ankle Hurts !! Chronic ankle pain and you.

Chronic lateral ankle pain symptoms

Chronic lateral ankle pain is characterized by swelling and stiffness near the ankle joint, as well as recurring pain on the outside of the ankle that worsens with exercise. The pain can be brought on by walking and playing sports, or it can manifest as a dull and constant ache. One of the more distressing symptoms of chronic lateral ankle pain is a constant feeling of ankle instability. People with chronic lateral ankle pain often have difficulty walking in high heels or on uneven ground and are prone to repeat ankle injuries.

Treatment of chronic lateral ankle pain 

Treatment for chronic lateral ankle pain will depend on the final diagnosis by your physician. Conservative treatments include:
Ankle brace (to fascillitate immobilization and prevent further injury).
Ankle arthroscopy (surgical exploration and repair of damaged cartilage)
Anti-inflammatory medication (to reduce swelling).
Physical therapy (designed to strengthen muscles and restore joint motion).
PRP injections (Natural autograft to enhance isolated tendon healing)
MRI examination (Typically for surgical planning to see the extent of the damage and planning for open repair)

Not all pain is arthritis based. And not all pain is attributable to a definitive trauma or injury. The history of chronic ankle pain and instability is usually multifactorial, and is often under treated and not diagnosed very well which may lead to tendon tears and progressive degenerative arthrosis. We will perform a complete examination which will allow for more accurate diagnosis and improved prognosis.

Dr Timm
Diplomate American Board of Podiatric Surgery

Does weather worsen arthritis?

"Doc, my ankles hurt more in the cold. Why is that?"

I get this question often from patients who are seasonally living in this area.

But does the weather actually affect arthritis? If so, how?

First, there hasn't been much real research science addressing this question. In 1961, famous arthritis specialist J. Hollander, MD, conducted a study in which he built a climate chamber and demonstrated that high humidity combined with low barometric pressure were associated with increased joint pain and stiffness. Neither weather factor by itself seemed to influence joint symptoms. The study has been criticized because of the limited number of patients evaluated (12 patients). The theory of the study is that inflamed joints swell as the barometric pressure drops. This swelling irritates the nerves around the joints that sense pain and causes more stiffness.

Well, if this theory proved correct (and it is not universally accepted), should a person with arthritis move to a region with a dry climate?

The answer is no. Relocating to a different climatic environment does not seem to make a difference in the long run. Scientific studies have shown that no matter where people live their bodies seem to establish a new equilibrium to the local climate. As a result, changes in the weather affect the arthritis symptoms in the same manner regardless of the actual overall average weather. Moving is not likely to be beneficial long term. (To emphasize a point, I can tell you that there are plenty of busy rheumatologists in Florida!)

What is the bottom line?

It appears that there is some evidence that the symptoms of certain people with arthritis are influenced by changes in the weather. This is not true for all people with arthritis, nor is it predictable what type of weather alterations will bother people. For example, in one room I may have a patient complaining that last week, just before it rained, her joints began aching and now that the weather is warm and clear she feels better. Simultaneously, in the next room, a patient tells me that her joints are far worse today after it rained last week! What do I do with this information? Well, each patient must be evaluated (and evaluate themselves) uniquely. The bottom line is that while the exact cause(s) of the activation of arthritis symptoms may not yet be scientifically understood, each patient must make lifestyle and/or medication adjustments according to the particular weather conditions that they note influence their symptoms.

If a patient does experience joint pain and stiffness with weather changes, how harmful is this?

It is very important to appreciate that only joint symptoms (such as pain and stiffness) are influenced by weather. We do not have any evidence that weather changes lead to joint damage. Furthermore, weather changes have not been related to whether or not an individual develops arthritis.

So enjoy the warmth while you're here, and remember to bundle up if you are still in the cold, as this may otherwise precipitate painful swelling and stiffness of your joints. 

Flatfeet could slow you down

How is this possible?

The results conducted by the American Podiatric Medical Association concluded that a staggering 73 percent of people asked said that they are suffering from foot pain.

The question is: why has foot pain become one of the most common complaints in the examination room?

For many people, this problem can be caused by one of the following: the kinds of shoes they wear, what activities they participate in, or how their feet are formed. Wearing poorly-fitting shoes can turn minor problems into major ones. People who engage in athletic activities are another segment of the population that are mostly affected by foot pain. Factors such as fallen arches, overpronation, and poor support can all be contributing factors to lower extremity pain. Parents can also be the cause of foot-related problems, because genetics play a role how the foot was formed in the womb. This can enhance the likelihood that someone will suffer from an array of painful foot conditions.

The Mechanics of the Foot
Flat feet can cause abnormal rotation of the feet when walking or running. Our feet handle balance, stability, and bear the weight of the body. The parts of the foot that help to keep the foot in harmony with the body include the arch, heel, tarsals and meta-tarsals. The arch provides stability by the following structures: the tendons, ligaments, and muscles. Pain can result from raised arches or abnormally-low arches, which can cause the foot to rotate abnormally. With high arches, the body’s weight is abnormally emphasized on the outer edge of the foot (oversupination). Conversely, overpronation happens with fallen arches because the weight of the body is concentrated on the inside of the foot, causing the ankles to roll inward .

Serious Foot Issues May Occur with Flat Feet A quick way to see if fallen arches or high arches are an issue is to find a good area where a foot impression can be made, such as on concrete. Immerse on foot in cold water and then stamp your foot onto the dry surface. Then, lift the foot off the ground and see the impression that is left by the foot. A flat foot with overpronation will leave a complete mark where the entire foot has touched the ground. A high arch will leave just a part of the ball of the foot’s outside portion, and heel of the foot. Either of these arch conditions can cause painful bony growths in the heel because the foot has to deal with too much pressure in places it is not intended to handle.

Orthotics Provide Effective Relief for Therapy For Plantar Fasciitis
People suffering from fallen arches, heel spurs, or who need plantar fasciitis treatment can get relief by using the best orthotics available in their shoes. They offer the needed support to fix the weak structures in the foot, such as those that make up the arch. They also offer cushioning in areas where too much pressure occurs, such as in the heel or ball of the foot. Orthotics are available in an array of sizes and types and are made to keep up with anyone’s activity level.

Not all bunions are the same!!

Must read - Bunions

A bunion is essentially a shift of the toe bones into the improper position causing pain and loss of function. The deformity involves the big toe and the long bone behind the big toe, the 1st metatarsal. Over time, the 1st metatarsal will begin to move towards the other foot (medial) while the big toe will move out of joint towards the 2nd toe (lateral). As the end of the 1st metatarsal bone begins to stick out, it will be under pressure from shoes and the ground. This constant pressure and friction will cause extra bone formation, leading to the bump that is seen on the side of the foot. The big toe will continue to shift towards the second toe causing an unbalanced big toe joint. Over time arthritis can develop in the joint due to the mal-positioned joint. 

A bunion deformity is always progressive. It will always get worse over time.



Severe bunion deformity with shift of the great toe under the second toe and hammertoe of the second toe.


Symptoms:
A bunion deformity does not always have to be associated with pain. Some patients have a very severe deformity and no pain, while others with a mild deformity have severe pain. Patients usually will have pain right over the bump with continued irritation and bruising to the bone from shoe gear and the ground forces. As the deformity progresses, pain will then be noticed in the joint itself when the big toe is moving. The big toe is very important during the gait cycle for pushing off the ground. With this imbalance of the joint there is a loss of the proper range of motion of the big toe joint leading to an inefficient gait. Over time arthritis will develop in the joint as the cartilage is scraped away each time the joint moves. The pain can be of different degrees depending on the degree of deformity, shoe gear, and activity level.

Causes:
Bunions are usually a genetic deformity. There is an imbalance of the muscles and the ligaments that are holding the 1st metatarsal in place. As this joint becomes weaker over time, the long metatarsal bone will begin to shift medially. The big toe is then under stress and begins to shift laterally under the pressure of the joint and shoes. Shoes with a tight and narrow toe box can help to create and make a bunion worse over time. High heeled shoes can also worsen and cause a bunion. Patients will a flat foot type (pronation) have a higher chance of having a bunion in the future.

Symptoms:
A bunion deformity does not always have to be associated with pain. Some patients have a very severe deformity and no pain, while others with a mild deformity have severe pain. Patients usually will have pain right over the bump with continued irritation and bruising to the bone from shoe gear and the ground forces. As the deformity progresses, pain will then be noticed in the joint itself when the big toe is moving. The big toe is very important during the gait cycle for pushing off the ground. With this imbalance of the joint there is a loss of the proper range of motion of the big toe joint leading to an inefficient gait. Over time arthritis will develop in the joint as the cartilage is scraped away each time the joint moves. The pain can be of different degrees depending on the degree of deformity, shoe gear, and activity level.

Diagnosis:

A clinical examination of the foot is done first. It is very important that the structure and biomechanics of the patient’s entire foot is examined. In order to identify the severity of the deformity, the stability of the joints around the bones involved is essential. The doctor will analyze the gait pattern of the patient. The doctor will identify if there is pain with joint movement and if the big toe can easily be re-located back into the joint. X-ray evaluation is essential in order to determine the degree of the bone shift and specific angles and the relationships between the bones.

Treatment Options:
Conservative treatments for bunions are limited. Wider shoe gear and accommodation for the deformity can be used to take the pressure off the area. Bracing and spacers are often used to brace the big toe back into position and can take some of the pressure of the big toe. However, this does not address the deformity and shift in the metatarsal bone. Furthermore, the bracing techniques are only work when used, once the brace is removed, the big toe will immediately go back into its deformed position. Custom molded Orthotics can take some pressure off the big toe and redistribute the forces of the ground through the rest of the foot. Orthotics can slow the progression of the deformity. There is no way to stop the progression or reverse the deformity without literally moving the bones back into the correct position and realigning the joint. This can only be accomplished through surgery.

We know that in order to realign the joint, the first metatarsal must be repositioned and fixated in the proper position. This can be accomplished by three basic types of procedures. First MPJ fusion, Offset Austin and Lapidus bunionectomy are the ideal procedures as they limit the chance of the bunion deformity from returning.

The choice of the procedure to be performed will be dictated by the severity of the deformity.


Mild Bunion Deformity 
In mild and moderate bunion cases, we try to allow patients to have a more rapid recovery and limit the amount of time they need to spend off their feet. The Tightrope and Offset Austin bunion procedures allow immediate weight on the foot in a boot and also allow for rapid return to shoes. The choice of procedure best for each patient depends on the deformity size, the stiffness of the 1st metatarsal and the ease of realignment of the 1st metatarsal during the clinical exam.



Drawing of a bunoin prior surgery. Note poor alignment of the great toe and the 1st metatarsal. Grey shaded are will be removed during surgery and dotted line shows the region of bone cut.



Drawing of bunion after surgery. Note the shift of the 1st metarsal towards the second meatarsal for realignment of the column and fixation of the bones together with the two screws from top to bottom.





Clinical representations of pre and post surgery of mild bunion corrections.

Severe Bunion Deformity 
In severe bunion cases, the 1st metatarsal is dramatically shifted away from the second metatarsal and there is looseness of the 1st metatarsal at the base of the bone. This is a difficult problem to correct unless the entire 1st metatarsal is realigned and held stable so it does not shift again. The Lapidus procedure allows for the 1st metatarsal to be repositioned with ideal correction and limited to no chance of bunion return. Recovery is slightly more difficult due to the need for crutches but the result is well worth it in difficult and severe cases. Some patients even require fusion of the first metatarsophalangeal joint secondary to this variation of deformity.

Hypermobility

The underlying cause of severe bunions is thought to be at the medial cuneiform joint and not at the great toe joint. If there is looseness of the medial cuneiform joint, there is motion of the metatarsal allowing the metatarsal to move out of position resulting in a bunion. The metatarsal may also move up resulting in poor position on the ground and collapse of the arch.

Clinical Pictures

Smokers Beware

Smoking and Bone Healing

Why are bones affected by smoking?


Bones are nourished by blood much like the other organs and tissues in your body. Nutrients, minerals, and oxygen are all supplied to the bones via the blood stream. Smoking elevates the levels of nicotine in your blood and this causes the blood vessels to constrict. Nicotine constricts blood vessels approximately 25% of their normal diameter. Because of the constriction of the vessels, decreased levels of nutrients are supplied to the bones. It is thought that this is the reason for the effect on bone healing, as the impending need for more oxygen and nutrients during fracture and osteotomy healing are not met, causing prolonged union time.

Evidence Based Medicine Review

"Cigarette smoking is detrimental to bony healing," said Dr. Franklin Chen, an orthopedics instructor at Northwestern University Medical School in Chicago, Illinois, and lead author of a report presented at the recent annual meeting of the American Academy of Orthopedic Surgeons (AAOS), held in New Orleans, Louisiana.
He and his colleagues focused on the 13-month healing rates of 54 patients who underwent surgery to help correct a specific type of (often work-related) wrist injury called symptomatic ulnar impaction syndrome. Chen says "95% of nonsmokers healed compared to 68% of smokers; this difference is statistically significant. The mean time to healing was 5 months for nonsmokers and 7.2 months for smokers." Previous studies have shown similar slower healing rates among smokers who have undergone spine or ankle fusion surgeries.

In essence: it is important to note that when I or any of the physicians at our office "lecture" to you about the cessation of smoking and it's direct impact on your healing potential, we are not just being mean. It's based on clinical evidence that is monumental for your optimal outcome. This can impact healing time in stress fractures and wound healing as well, so cessation is your best bet!!

We have even started a policy whereby we will NOT perform ANY elective surgery on a smoker unless you either stop smoking 1 month prior to date of surgery and stop for 3 months after the surgery is completed, or sign a "WAVER" which specifically states that you understand you are directly impacting your outcome and any and all unforseen complications (such as infection, ampuatation, nonunion, etc) are DIRECTLY related to NON COMPLIANCE.

Dr Timm

What you need to know about "Turf Toe"

Turf Toe

The simplest definition of turf toe is that it is a sprain of the main joint of the big toe. It happens when the toe is forcibly bent up into hyperextension, such as when pushing off into a sprint and having the toe get stuck flat on the ground.

Sprains of the big toe joint became especially prevalent in American football players after artificial turf became more common on playing fields - hence the term "turf toe." Artificial turf is a harder surface than grass and does not have much "give" when forces are placed on it.

Although often associated with football, turf toe occurs in a wide range of sports and activities.

The typical position of the foot when a turf toe injury occurs.

Anatomy

The big toe is made up of two joints. The largest of the two is the metatarsophalangeal joint (MTP), where the first long bone of the foot (metatarsal) meets the first bone of the toe (phalanx). In turf toe, the MTP joint is injured.

The MTP joint is the large joint closest to the base of the big toe.

The joint is surrounded by important structures that hold it in place and prevent it from dislocating. Together these structures are referred to as the "plantar complex."

• Plantar plate. This thick, fibrous tissue under the MTP joint prevents the big toe from bending too far (dorsiflexion).
• Collateral ligaments. Located on each side of the big toe, collateral ligaments connect the phalanx bone to the metatarsal and prevent the toe from going too far side-to-side.
• Flexor hallucis brevis. This tendon runs under the first metatarsal bone and attaches to the phalanx. It provides strength and stability to the big toe during push-off motions.
• Sesamoids. These two small bones are enveloped in the flexor hallucis tendon, and help it to move more easily. In addition, the sesamoids provide stability to the MTP joint by helping to bear weight placed on the forefoot.

Several structures work together to protect and stabilize the MTP joint.

Description

The term "turf toe" refers to an injury of any soft tissue structure in the plantar complex, such as the plantar plate or a collateral ligament. These injuries can vary in severity — from stretching of the soft tissue to partial tearing, and even total dislocation of the MTP joint.

To help them plan treatment for turf toe, doctors grade the injuries from 1 to 3 - mild to severe.

• Grade 1. The plantar complex has been stretched causing pin-point tenderness and slight swelling.
• Grade 2. A partial tearing of the plantar complex causes more widespread tenderness, moderate swelling, and bruising. Movement of the toe is limited and painful.
• Grade 3. The plantar complex is completely torn causing severe tenderness, severe swelling, and bruising. It is difficult and painful to move the big toe.

We have treated this injury on and off over the years with similar therapy. Rarely does this require surgery, and there is sparse literature which can be referenced to delineate whether grade 1 and grade 3 injuries are specifically nonsurgical or surgical.  We have used a combination of PRP injections with hallux extension BK casting for this injury and have found good success. This is a non surgical approach and has had with it some good short term success. But this may still be a devastating injury for most athletes. (Even notable pros such as Deion Sanders, have had career ending versions of this injury).