Rapid-fire Lower Extremity Pathology!

As we wind down the month during which time we’ve discussed some uncommon lower extremity pathologies, I thought this week we would take a rapid-fire approach. We will touch very briefly on several lower extremities pathologies and encourage you to comment or write in if you have questions regarding any of the areas presented. Let’s get started! Buerger’s Disease (BD): Young male patients with a history of cigarette smoke, who suffer from intermittent claudication (pain in their legs with activity) that limits the amount of activity they can perform, can often times be diagnosed with Peripheral Vascular Disease (PVD). A pathology we’ve talked about in the past, where flow of blood from the heart to the legs is limited secondary to narrowing of the blood vessels. However, Buerger’s Disease should be ruled out as the symptoms are the same as PVD, but the pathology is quite different. In BD, the blood vessels become inflamed, swollen and blocked at various levels by clots resulting in decreased blood flow. The risk factors include genetic predisposition (family history), chronic gum disease and cigarette smoking. Those patients with advanced disease must quit smoking or risk amputations as the disease progresses.

Haxthausen’s Disease (HD): This disease, often confused with dry skin and other skin conditions that produce thick, callus-like scales on the hands and feet is found in post-menopausal women. The condition is typically associated with arthritis, obesity and hypertension and is difficult to diagnose because of the numerous skin diseases in a Podiatrist’s repertoire and HD’s rarity. It has been documented that a link between HD and psycho-emotional conditions and metabolic disorders exists, however there are too few cases to predict this with any certainty. The skin lesions first appear on the soles of the feet and progress to the palms of the hands. Treatment consists of topical steroids to treat the itch and inflammation, along with heavy application of moisturizers. If left untreated, the itch can become so severe and the rash so progressed that sloughing of the skin and creation of painful fissures occurs.

Trench Foot: This pathology has a very distinct clientele associated with it: individuals with trench warfare experience. It is also known as immersion foot and is so named as it occurs as a result of immersion of one’s foot in wet and cold environments for a prolonged time period. When the feet become wet and cold at the same time, the blood vessels constrict, decreasing blood flow to the affected areas and if not treated by removing wet socks and shoes while re-warming the feet, permanent damage to the nerves and blood vessels can occur. In the unlucky soldier, permanent damage results in chronic itching, pain and swelling of the feet with blotchy skin changes, scaling and a “heavy” feeling to the feet. Patients with the long-term sequelae of Trench Foot will require long-term care by a Podiatrist.

Lobster Foot: Picture a lobster claw…Lobster Foot is a rare congenital (inherited) abnormality, present at birth where one or both feet are missing what are called the “three central rays.” What this means is that toes 2, 3 and 4 are missing, along with their corresponding long bones (metatarsals), responsible for connecting the toes to the middle portion of the foot. This absence leaves only the 1st and 5th toes and their corresponding metatarsals in place, creating the look of a lobster claw. Treatment of this pathology aims to restore function to a foot that would otherwise be non-functional and impossible to bear weight on. Each case is treated independently, but typically requires surgery where both bone and soft tissues are part of the solution.

Macrodactyly: This is a rare, congenital abnormality that is not present at birth, but rather becomes more and more obvious as the patient ages. It is a form of “localized gigantism” where one digit becomes much larger than the others with growth. Each case is different and may or may not be associated with simultaneous enlargement of tendons, nerves and blood vessels in the affected digit. One thing that is common however is an increase in the amount of skin covering the digit, as it is a necessary part of accommodating the toes growth and often presents the greatest challenge in reducing the size of the digit. Numerous surgical procedures from size reduction and amputation have been attempted, but secondary to our unclear understanding of this pathologies etiology, recurrence is very common.

Well, that concludes this weeks “Rapid-fire!” As a Podiatrist, the saying, “when you hear horse-hoofs, think horses, not zebra’s” applies, but every once in a while, a zebra might just be walking into the office. I hope you’ve enjoyed this month articles covering ‘Zebra-like’ (uncommon) pathologies!

Red, White and Blue!!

As we continue our journey this month through some of the more uncommon podiatric injuries, pathologies and diagnoses, I’d like to discuss Raynauds Disease. Raynauds is defined as an abnormal or overly aggressive constriction of the small arteries in the toes and fingers precipitated by exposure to cold temperatures. When the small arteries constrict, circulation to the toes and fingers becomes limited and the perception on behalf of the patient is that those areas of the body are numb.

Raynauds, also known as the “red, white and blue syndrome” secondary to its clinical presentation, is most common in women and is often undiagnosed. Patients disregard symptoms as normal or non-important during cold winter months when fingers and toes are typically cold, and thus their symptoms go unreported to physicians. The signs and symptoms are related to the severity of the disease, but as mentioned typically present as cold or numb toes and fingers (digits). As the pathology progresses, the digits become red in color, followed by white, followed by blue, signaling the most severe stage of the disease and living up to its nickname!

Patients suffering from raynauds do not experience a constant feeling of cold, tingling or numbness in their digits, but rather the symptoms appear during raynaud “attacks.” It can, on some level be related to an asthma attack whereby exposure to aggravating factors induces symptoms. These attacks can target just one or two toes or fingers or may affect all toes and fingers simultaneously. Symptoms appear secondary to exposure to cold temperatures (most commonly) and may appear during times of physical or emotion stress. Hormones produced during times of stress change balances within the body and may lead to attacks and presentation of symptoms. However, the underlying etiology of Raynauds Disease and why some individuals suffer from it, and not others, is largely unknown.

What we do know is that a secondary form of raynauds exists, where symptoms present as a side effect of other disease states such as: Scleroderma, Lupus, Rheumatoid Arthritis, Sjogren’s syndrome, trauma, and smoking to name a few. When associated with such pathologies, raynauds is referred to as “Raynauds Phenomenon” (as opposed to raynauds disease) and tends to induce slightly more serious attacks.

To determine the presence of raynauds and to separate the disease from the phenomenon, clinical presentation in addition to a complete medical history taken by your Podiatrist is necessary. A cold-stimulation test, where the toes are placed in cool water to trigger an attack can be used to help aid in diagnosis, but is rarely performed or necessary. Blood work may be drawn to help rule out any of the underlying diseases specific to the phenomenon, versus primary raynauds where there is no associated disease.

Besides enduring symptoms between attacks and holding out for summer when the winter weather fades and the temperatures rise, patients rarely experience debilitating consequences. However, if severe cases do occur, complications arise from permanent constriction of one of the small arteries within the toes or fingers, compromising blood flow to the area. Permanent constriction can lead to ulcerations with the inability of these ulcerations to heal and in the worst-case scenario, loss of the involved digits.

Prevention of attacks is the best attitude to take with raynauds. Keeping the severity and numbers of attacks to a minimal helps prevent tissue damage and permanent constriction. Therefore, keeping your hands and feet warm with heavy gloves and socks is a must, especially during winter! In addition, daily checks of fingers and toes can help catch early signs of ulceration, so that further skin damage and breakdown don’t occur. Bi-annual checkups by your Podiatrists are also recommended, especially for patients with associated disease states or difficulty visualizing their own feet. Medications can be used, but are reserved for severe cases and most patients will never need to take medications for treatment of their raynauds. Such agents are aimed at dilating blood vessels to promote circulation and decrease the risk of constriction.

Check back next week as we tackle yet another uncommon podiatric diagnosis!

Navicular Fractures

Over the last year or so, we’ve covered many topics and have certainly hit on some of the more common pathologies in the world of Podiatric Medicine. Over the next month, I’m going to be blogging about some less common diagnosis and pathologies.

To start us off into the world of rare pathologies, we will be covering navicular fractures this week. A navicular fracture is rare but can be seen, especially in athletes. First, lets talk about what and where the navicular bone is.

The navicular is a bone in the foot also known as the scaphoid bone. It is located towards the inside of the foot (medially) between the heel and the metatarsals. It can be found by running your fingers along the inside of the foot starting at the heel and moving towards the toes. As you slide your fingers along your foot, the first small bump/bulge you feel indicates the location of the navicular. The bone extends from the medial side of the foot, half way across the top over to the outside (lateral side) of the foot. Picture a sideways teardrop-shaped piece of bone that serves as a stabilizer of the foot, particularly the arch.

The best way to discuss navicular fractures is to break them down by the type of fracture suffered. Navicular fractures come in 4 types, as classified by the Watson and Jones Classification System (here we go again: we Podiatrists classifying and naming everything)! Each type of fracture results from a slightly different mechanism of injury and, thus are treated according to that mechanism.

1. Avulsion fracture of the most medial side (fracture of the palpable bump along the inside of the foot). At this area of the bone a large tendon, known as the Posterior Tibial Tendon, responsible for supporting the arch of the foot, attaches. An avulsion injury occurs when increased tension is placed on the tendon while the foot is moving away from the body, whereby the strength of the tendon pulls off (avulses) the most prominent piece of the navicular bone. Most of these fracture fragments remain in close proximity to the main portion of the navicular and will heal properly with immediate immobilization via casting and non-weight bearing for at least 4 to 6 weeks.

2. Chip fracture off of the top surface of the bone. This type of navicular fracture is the most common of the 4 types (although still a rare injury) and can also be referred to as an avulsion injury. Although this time it is not a tendon that is pulling off a piece of bone, but rather a ligament on the top of the foot that becomes tensioned while the foot is moving downward and inward at the same time. If the avulsed fragment is small, casting with non-weight bearing for 4 to 6 weeks is indicated, but if the fragment is much larger surgery may be required to accurately reposition the fragments.

3. Fracture of the body. This type of navicular injury is the least common fracture type and typically results from direct injury, such as a can of soup tumbling out of the pantry and falling onto the foot! The fracture line usually extends from the top to the bottom of the foot, splitting the bone in half. If the two pieces remain close in proximity, casting with non-weight bearing for 4 to 6 weeks is adequate treatment. However, if the pieces become separated or if there are more than two pieces created with injury, surgery may be indicated to re-approximate the fragments and encourage a greater chance for healing.

4. Stress fracture of the body of the navicular. This diagnosis is commonly overlooked because the injury is very difficult to evaluate on standard x-ray therefore, diagnosis comes with a high index of suspicion on the part of your Podiatrist. Sufferers of navicular stress fractures are commonly track and field athletes who describe vague and diffuse pain in the midfoot region. If not recognized and treated with immobilization immediately, a stress fracture can lead to complete fracture.

Navicular fractures can be treated in a fairly straightforward fashion, by recognition and casting with non-weight bearing until healing has been achieved. Unless the fracture fragments are displaced (separated from one another), surgery can typically be avoided. Navicular fracture may not be the first injury to come to mind in foot and ankle injuries, as it is fairly uncommon, but it can be seen!

Tailors Bunion Surgical Repair

We just talked about what a tailors bunion is, including why it forms and how it can be treated conservatively. Just to refresh, a tailors bunion is much like the typical bunion except that it is located on the outside of the foot rather than the inside. The bone affected when a tailors bunion develops is the 5th metatarsal bone. There are a total of 5 metatarsal bones in the foot, each corresponding with a toe, such that the 5th metatarsal is located between the rearfoot and the 5th toe, along the outside of the foot.

Aside from an inherited bowing of the 5th metatarsal outward, most tailors bunions are caused by splaying of the foot with gait. This means that with each step, the foot widens out and when the sides of the foot come in contact with the shoe, excess pressure develops and eventually pain. As a result of the excess pressure, responses from both the skin and bone underneath the pressure area induce the formation of thickened skin (callus) and reactive bone growth on the head of the 5th metatarsal, creating the characteristic baby “bump” that is your tailors bunion.

There are a variety of conservative measures which we have already covered, so the aim this week is to briefly review a few of the more common surgical options, should all conservative methods fail.

Soft Tissue Procedures: Although there are various soft tissue procedures that can be used to correct for the traditional bunion located on the inside of the foot, because there are fewer and small structures surrounding the 5th metatarsal, 5th toe and outside of the foot, soft tissue procedures are typically unsuccessful and rarely attempted.

Bone Procedures: When addressing a tailors bunion there are two main options for which bowing of the metatarsal and reactive bone growth can be addressed. There is a “shave the bump” method and a “bone cut” method.

-Shaving the bump: This procedure basically involves removing or shaving off the outside portion of the 5th metatarsal head to prevent it from pushing up against a shoe. The reactive bone growth in addition to a small amount of the normal bone would be removed and smoothed down decreasing the size of the bump. This type of procedure does not require any pins or screws for fixation and is typically used for mild deformities with great success.

- Bone cuts: There are numerous procedures that can be performed where a bone cut would be made, but no matter which type of cut, all procedures aim to achieve the same result: decreasing the deformity and reducing pain/pressure. A bone cut allows the head of the bone (the portion closest to the toe) to be shifted over/inward that after healing reduces splaying of the foot with gait, decreasing pressure of the metatarsal bone against the shoe. This procedure does require a pin or screw that can be temporary or permanent depending on your Podiatrists preference, and is indicated for large tailors bunions.

As with any surgical procedure the risks and benefits should be considered and discussed with your Podiatrist. Complications with any of the tailors bunion procedures described above can include infection, scarring, recurrence of deformity, and transfer pain among others, although the risks of any such complications are minimal. Patients should expect anywhere from 2-6 weeks of recovery depending on the procedure selected and they should expect pain typical of healing during the recovery period, in addition to lingering swelling. Again, all conservative options should be explored prior to surgical intervention, but should surgery be appropriate, patients tend to do very well!

What’s a Baby Bunion?

A baby bunion, bunionette or tailors bunion are all terms used to describe a bunion deformity along the outside of the foot. When we think of a traditional bunion, we think about the big toe being involved and typically an associated bump on the inside of the foot that becomes painful with shoe wear and activity. A bunionette is essentially the same problem, but instead of involving the inside of the foot and the big toe, it involves the outside of the foot and the little toe.

The term tailor’s bunion, as it is commonly referred to in the Podiatric world, derived its name from clothing tailors who would sit on the floor cross-legged, while tailoring pants. Pressure between the ground and the outside of the foot while the tailors were working led to pain and irritation with the creation of a small bump in the area and thus the term Tailors bunions.

Although Tailors, at least good ones, are becoming increasingly harder to find, this deformity still presents itself quite frequently in a Podiatric practice. The same etiology applies today, although the pressure isn’t between the foot and the floor, but rather the outside of the foot and a tight-fitting shoe. Now, lets be clear about one thing, it is not solely pressure that causes pain along the outside of the foot and creation of a tailors bunion, but when that pressure is combined with predisposing foot types, the result is often a bunionette.

Foot types that predispose individuals to the development of a tailor’s bunion are numerous but the most associated foot type is called a splay foot. A splay foot, is exactly what it sounds like: It is a foot that with walking will splay or spread out fairly widely requiring a greater amount of space for normal walking. When the foot wants to spread widely, but due to the constraints of shoes it is not able to, the foot gets pressed up against the sides of the shoe and begins to rub and become irritate. The rubbing and irritation leads to responses from both the skin and bone underneath the pressure area leading to callous formation and reactive bone growth, creating that ‘bump.’

In some instances, a congenital outward bowing of the 5th metatarsal bone (the 5th long bone in the foot between the rearfoot and forefoot) is the root cause. In patients with this congenital bone abnormality, tailors bunions may present sooner in life, rather than in a patients 40’s or 50’s as the typical tailors bunion does.

Treatment options include a vast array of choices from conservative to surgical and the choice depends largely on the patients pain and discomfort in combination with a physical and clinical examination of the condition. Your Podiatrist will ask you a variety of questions to determine how fast the deformity is progressing and what methods of treatment, if any, you have previously tried. They will examine the deformity clinically to determine where the pain is localized to, the degree of soft tissue involvement, the condition of the joint, the rigidity of deformity, and the underlying etiology. Your Podiatrist will also take bilateral radiographs of your feet to evaluate the joint and bone positions in comparison to “standard” radiographic angles.

Once all the pieces of the examination have been considered together, it is most likely that conservative options will be exhausted prior to surgical intervention. Conservative treatments include: periodic shaving of the calloused tissue to relieve pressure; injections to decrease inflammation and alleviate pain; padding of the toe to decrease pressure with shoes; and orthotics, which attempt to realign the foot in a more optimal position decreasing the splaying of the foot that may be the root etiology of your tailors bunion.

If all conservative treatment options have been explored and the patient still complains of a significant amount of discomfort, surgical options are the next step. Next week we will talk about several of the surgical options for treating you tailors bunion and what to expect if you opt for surgery.

Lower Extremity Skin Cancers

In last weeks article we discussed the ABC’s of Skin Care and stressed the importance of self-skin evaluations in helping to catch early signs of changing lesions that may be indicators for larger problems. This week we will cover some of the specific types of skin cancers seen on the lower extremities, helping you develop an understanding of why prevention and early recognition are key.

We will discuss three types of skin cancers that can be seen on the lower extremity: Basal Cell Carcinoma, Squamous Cell Carcinoma and Malignant Melanoma. The major risk factors for all three types of skin cancers discussed this week are chronic sun exposure especially in individuals with fair skin, in addition to increased age, a history of skin cancer and a compromised immune system.

Identification and diagnosis of any cancer begins with suspicion. As was stressed last week, if you are suspicious about any lesions or review of your “ABC’s” you should see your doctor as soon as possible. If they evaluate the lesion and there is reason for suspicion on their behalf they will either refer you to a specialist for further evaluation or take a biopsy of the questionable lesion. There are a variety of ways to biopsy lesions and the choice largely depends on your doctor’s preference and the presenting lesion, but some form of biopsy with evaluation by a pathologist is required for diagnosis.

Basal Cell Carcinoma: This is the most common malignant skin cancer and is typically slow growing and locally destructive. Cells in the basal layer of the skins epidermis are actively growing and when their growth is disrupted or kicked into high gear, basal cell carcinoma can result. Basal cell carcinoma has several subtypes, as do the other skin cancers discussed, with the classification largely dependent on the presentation of the initial lesion. There is very little potential for this type of cancer to metastasize (spread to other areas of the body), making treatment >95% curative.

Squamous Cell Carcinoma: This type of skin cancer is typically slow growing, and if caught early on can be treated with high likelihood for a full recovery, which is why following the ABC’s of skin care are so important. Changes in cells within the top layer, or epidermis of the skin can progress to squamous cell carcinoma when they are no longer pushed to the top and sloughed off as dry skin. In addition to the major risk factors for the three types of skin cancer discussed this week, exposure to chemical carcinogens and prior radiation therapy can specifically predispose a patient to development of squamous cell carcinoma. There are several forms of squamous cell carcinoma with some types more apt to metastasis than others, thus early identification is key!

Malignant Melanoma: This is the most dangerous form of skin cancer and is also the most common life-threatening problem in dermatology today, especially in young-persons. Most types are darkly pigmented, as melanocytes are the cells that go awry in melanoma and are also responsible for the color of our skin. Melanoma can be divided into 5 sub-types depending on the characteristic appearance of the lesion and the cancers ability to spread. You should pay particular attention to darkly pigmented toenails, as most are benign, but should the pigmentation spread beyond the nail itself and onto the surrounding skin, see your Podiatrist as soon as possible.

Treatment for each type of skin cancer described above depends on a variety of factors including how far the lesion has spread both in length and depth through the skin layers. Most will require excision of the lesion, but more aggressive forms or those lesions which are deeper into the layers of the skin may require radiation, chemotherapy, or other medicines for treatment and remission potential.

To reiterate, prevention is your best friend when it comes to skin cancer and with sun exposure being the greatest risk factor, never forget to wear your sunscreen! However, we are all human and we sometimes forget, so following the ABC’s and checking your skin on a regular basis will help catch any changing lesions early on and improve your chances of recovery should one of those lesions turn out to be a form of skin cancer.

Never hesitate to consult your Podiatrist and Dermatologist if you have concerns!

The ABC’s of Skin Care

As the winter snow melts away and the sun begins to shine we can rest assure that spring is headed our way and shortly behind it, summer! That’s the time of the year when we hit the beaches, kick up our outside workout routines and picnic at local state parks hoping to catch some rays. As you pack your lunches, fill your water bottle and throw your bathing suits on, don’t forget the sunscreen!!

Sunscreen should be worn daily on your hands and face, even in the winter months, as those areas are always exposed to the sun. However, as we peel off layers of clothing with increasing spring and summer temperatures, it’s important to apply sunscreen to any exposed area of skin and ensure that our kids and loved ones are also slathering up. Exposure to the suns rays without skin protection is the largest risk for the development of skin cancers.

In addition to protecting our skin and decreasing the risk of associated skin problems, we need to remember to check our skin for new freckles and areas of changing color/pigmentation. If you check your skin daily or at least weekly, you can catch areas of changing pigmentation and new freckles that might be concerning before they become a real problem.

The ABC’s of Skin Care are listed below and provide a guideline for those daily/weekly skin checks. If any areas or your skin exhibits signs of A, B, C, D or E it should raise your index of suspicion and prompt you to follow up with a Dermatologist, or Podiatrist if these are areas on your feet.

A – Asymmetry: The lesion is asymmetric if you bisect it and the two halves are not symmetrical.

B – Border: Any border that is raised, scalloped or blurry may be abnormal.

C – Color: If the lesion is more than one shade or several different colors, or if the coloration of the lesion has changed, take notice.

D – Diameter: Any lesions larger than 6mm (the size of a pencil eraser) or a lesion that is growing in size, should raise cause for concern.

E – Elevation: Any lesion that is raised off the surface of the skin is considered elevated, and is worth having your Dermatologist or Podiatrist take a look.

Noticing any of these changes early-on significantly improves your long term outcome should any of the lesions turn out to be skin cancer, and if they turn out not to be skin cancers, you can sleep easy at night knowing that.

Just as a reminder, here are some things you can do to help decrease your risks:

Always apply sunscreen before leaving the house, especially to your face and hands, as they are always exposed to the sun.

NEVER tan in a tanning booth.

Check your skin daily, or at least weekly, using the ABC’s as a gauge of changing freckles or new areas of interest.

Schedule your yearly Dermatologist check-up. They can assure you aren’t missing any skin changes putting your mind at ease.

If you notice any areas of new or changing discolorations on your feet or around your toenails, especially changes that are darkly pigmented, see your Podiatrist for evaluation.


Next week we’ll tackle some of the specific cancers that can be seen on the lower extremities. This information is not intended to scare you or to induce paranoia, but rather to inform you so that you can decrease your risks and live a long, healthy life!