Monday, August 22, 2011

Sometimes Pain is Good

By now I’m sure we are all familiar with Type 2 Diabetes Mellitus (DM). It is a disease that touches almost everyone’s life. Let’s quickly review what DM is. After eating a meal containing carbohydrates, the body breaks down the food and absorbs the available nutrients, which in turn increases the amount of sugar in the blood. In order to use that sugar, the body secretes insulin to move the sugar out of the blood and into our cells. In DM, our cells become insensitive to insulin, so that even if insulin is present, the sugar stays in the blood.

So your blood sugar is higher. So what? It doesn’t cause any pain, so why worry about it? Therein lies the problem! We need pain… Let me explain.

The problems with high blood sugar are numerous, and I hope to eventually address all aspects of this condition in future blog posts. But for now, we will focus the discussion around the notion of losing protective pain sensation. We have millions of nerve endings in our skin and bone that signal pain. With prolonged periods of high blood sugar, those nerves begin to swell and lose their capacity to function properly. As a result, we lose the ability to sense pain in our extremities, especially in the foot and ankle.

Sounds like a nice side effect right? Wouldn’t life be great if all the foot aches and pains we experience suddenly disappeared? You might be tempted to agree, but in truth, pain serves a very important purpose. Pain keeps us from engaging in activities that have potential to injure vital structures in the body. It alerts our brain to immediate needs that need to be addressed. Without it, you are at risk of injuring yourself without even knowing it. Instead of feeling the pain of a minor cut on a toe and applying a band aid, you don’t feel anything and walk around with an open cut ripe for infection. Losing pain sensation is known as Peripheral Neuropathy, and it commonly accompanies DM. Peripheral Neuropathy is often the root cause of many problems faced by diabetics.

Hopefully, it is clear why pain so is important to being healthy and why blood sugar needs to be tightly controlled. But if I haven’t scared you yet, stay tuned for next week’s blog. We’ll discuss a devastating complication of peripheral neuropathy that severely handicaps the foot’s function. And the worst part about it is that you won’t even feel it!

Tuesday, August 16, 2011

Pre-dislocation Options

We’ve discussed pre-dislocation syndrome’s signs and symptoms, as well as conservative treatment available to stop its progression. Even with early recognition and immediate treatment, pre-dislocation syndrome can progress to a chronic issue and require surgical treatment. No one individual surgical option fits every situation, and each case must be examined for the underlying cause to determine which surgical procedure to use. Talk with your doctor to know which surgical option fits your circumstances the best. We’ll discuss two ways to surgically address pre-dislocation syndrome.

One surgical option is to directly go in and repair the plantar plate. Remember, the plantar plate is the thickened portion of the joint capsule on the bottom side of the foot that prevents your toes from dislocating. To repair this, the surgeon would make a cut on the bottom of the foot under the affected toe joint. The surgeon would then proceed to sew the planter plate back together using sutures. The toe will be placed back into its correct position and the plantar plate will be tightened. Sewing the plantar plate back together will allow it to heal quicker and regain its proper strength. Healing time is between 5-6 weeks, but during that time, you can wear a small boot and walk on it. Most patients have little to no downtime or pain.

Another surgical option is to do a flexor tendon transfer. Can you curl your toes up? If so, this procedure will be easy to understand. When you curl your toes, you are flexing them. This happens because the muscles that flex your toes attach to bone on the bottom side of the toes. What if we took that tendon and moved it so it attached to the top side of the toe? When you flex your toes, it would have a greater pull on the top side of the toe to stay down and not dislocate toward the top side of the foot. This would directly fight the problem that pre-dislocation syndrome presents. The only side effect of this procedure would be that you may have some stiffness of that toe. However, most patients have little to no pain. Some studies have even shown that combining a plantar plate repair with a tendon transfer was more effective in the long run than either procedure done alone.

There are many other procedures available, including replacing the joint with an implant, joint fusion, or shortening a metatarsal bone that is too long. These procedures are beyond the scope of this blog, but your podiatric surgeon will know when these more aggressive procedures are needed.

Why can’t I get this pebble out of my shoe?

We all know how bad it hurts to walk around with something in our shoe. Most of us can’t tolerate more than a few steps before we stop to untie the shoe to alleviate the pain. But imagine if you looked in the shoe and were surprised to find no rock, no foreign object. Think about having to walk around all day with the feeling of a rock in your shoe, and having that pain get even worse when you walk barefoot. If you have ever felt what I am describing, you may have what is termed Pre-dislocation Syndrome.

In the foot, there are 5 long bones called metatarsals. They extend down toward the toes, where they join your toe bones to form a joint. These 5 joints make up what we call the “ball of the foot”. Around each joint is a capsule, which is a fibrous, circular covering that protects the joint and prevents dislocation of the toes. On the bottom side of the foot, the capsule becomes especially thick and strong, and it is referred to as the “plantar plate.” With increasing age, high heeled shoes, or a sudden increase in physical activity, the plantar plate can be injured. With injury, the plantar plate becomes weak and is less capable of stabilizing the joint. Instead of your toes having a solid foundation to rest, they start to partially dislocate toward the top side of your foot. This condition, known as Pre-dislocation syndrome, can give the sensation of walking around with an invisible rock in your shoe right under the ball of your foot. This phenomenon is jokingly called “Floating Toe Syndrome” since your toes start to move around uncontrollably as you walk. Although this can happen with any of the toes, it most commonly happens with the 2nd toe.

Go ahead… Look under your foot. If you see a grape-sized lump under any of your toes, and you have pain that goes away with rest, you may have this condition. Fortunately, as the name implies, the toe is not fully dislocated and can be treated to relieve the pain.

We’ll discuss next time some of the treatment options available to combat the your floating toes.

Take 5!

As we’ve discussed before in our Blogs on Diabetes, prevention is by far the best option patients have in protecting themselves from diabetic foot complications. The nature of the disease predisposes patients to decreased neurovascular signs (decreased blood flow and decreased sensation) in the small vessels and nerves, leading to a failure to recognize a problem and long-term healing difficulties. Through daily management, many of the complications of Diabetes in the lower extremity can be prevented and/or minimized. These 5 daily “Do’s” will help decrease your risk and increase your quality of life in managing Diabetes.

1. Proper Nutrition and Exercise: Maintaining a healthy diet and exercise routine (30 minutes 3 times per week) not only makes you feel good, but also keeps your weight down, and ensures that you are taking in all the necessary nutrients to increase your chance of healing, should you suffer a diabetic foot wound.

2. Monitor your blood glucose levels daily: It is important to maintain your blood glucose levels within a healthy range to prevent complications of Diabetes. You want to ensure that your pre-meal glucose levels are between 90-130 mg/dl and your post-meal glucose levels are less than 180 mg/dl. Any value above 180 mg/dL significantly mutes your bodies own immune response to infection.

3. Be vigilant: Taking medications prescribed by your doctors is important in controlling your co-morbidities, which may have a tendency to increase your diabetic complication risks. By maintaining your cholesterol, blood pressure, and glucose levels through prescription medications, diet and exercise, you can decrease your risk of ulceration and future complications related to Diabetes.

4. Check your feet daily: You are your best resource for catching early signs of skin breakdown, ulceration, and infection. The earlier you detect areas of concern and make an appointment with your Podiatrist, the faster you will receive treatment and the less likely you are to increase your risk of associated complications. Make sure you are never walking around the house without supportive shoes, you are washing all areas of your feet, including in between your toes, and drying those same areas thoroughly. Do not soak your feet in warm or hot baths and do not attempt to perform “bathroom surgery” for trimming of corns, calluses or nails. Leave the trimming and nail care to your Podiatrist. If you fail to check your feet daily, you become your own risk factor for a development of future problems!

5. Quit smoking: Smoking has a tendency to increase your heart rate and your blood pressure, while decreasing the amount of oxygen traveling with your blood cells to your extremities. The decreased flow of oxygen to your extremities decreases healing and increases your risk of complications should ulceration arise.

Following up with both your Podiatrist and your Primary Care Physician on a regular basis is important for keeping track of both your diabetes management and risk factors for complications, however you must be your own advocate. Taking 5! daily can significantly improve your long-term health and diabetes management.

It Feels Like My Ankle is Constantly “Giving Out.”

Often we have patients who present to the office with a feeling of “giving out” of their ankle that is not typically preceded by a triggering event at the moment they suffer that feeling. They often have associated ankle pain and relay a long history of athletic related ankle sprains or ankle fracture in the past. That one phrase, of feeling as if the ankle will “give out” combined with the patient’s history is often diagnostic of a common condition called Chronic Ankle Instability.

Instability at the ankle typically stems from the outside or lateral part of the ankle joint, where the most commonly injured ligaments in ankle sprains reside. The internal twisting of the leg and foot with an ankle sprain often times stretches, tears or ruptures these ligaments, and it is often very difficult for those ligaments to heal. In addition, healing takes place in a non-uniform fashion with improper rehabilitation, as most ankle sprains typically go unevaluated and untreated by the patients Podiatrist.

There are three main ligaments that make up the lateral ankle ligaments and often two of those are easily damaged in ankle injuries eventually leading to chronic instability secondary to laxity within these ligaments. The cycle is continues. Once those lateral ligaments are damaged, they tend to lengthen and have less inherent stability than prior to the first ankle sprain injury. This makes them prone to additional injury that occurs over and over again. In addition to a history of initial sprain, patients with a high-arched (cavus) foot type are prone to ankle injuries and eventual ankle instability because of the nature of their foot shape. The way the foot sits in this foot type lends itself to an increased risk of injury and eventual ankle instability.

Several diagnostic examinations can be performed to help the Podiatrist hone in on ankle instability as the underlying cause of a patient’s condition.

The first is simple palpation of the ankle joint. In any of these instances it is important to rule out any type of fracture to either the ankle or foot bones, so palpation of crucial areas is important. However, pain over the direct area where these lateral ankle ligaments reside is diagnostic of injury, especially when there is no pain on palpation to the bones that make up the ankle joint.

The remaining two examinations can be done with the aid of x-ray, where by the ankle joint is passively moved by the x-ray technician to specifically evaluate the strength of the tendon when compared to the opposite, unaffected ankle. The technician will try to pull the heel forward while stabilizing the leg in an examination called the Anterior Drawer Test, effectively evaluating the integrity of one of the lateral ankle ligaments. The next examination, referred to as Talar Tilt, evaluating the integrity of a different lateral ankle ligament. Positive results in performing either or both of these examinations indicates damage to the involved ligaments and thus is diagnostic of instability when associated with symptoms.

The key with chronic instability is to catch the instability before it becomes a chronic reoccurring problem. Early ankle support with bracing in addition to physical therapy will help decrease the healing time and increase the feedback from these ligaments as well as the ankle joint, helping to increase stability on the affected leg and reduce the occurrences of “giving out” episodes.