Getting Ready to String Up Some Holiday Lights?

You Might Just be Making Your Heel a Little Nervous!

Believe it or not, the number of heel bone (calcaneal) fractures that Foot and Ankle specialist see in their office tends to increase around this time of year. Certainly we get an increase in ankle fractures when the snow starts to arrive, but often people wonder about why heel fracture numbers go up. I’ll tell you a little secret: people start climbing ladders to hang holiday lights, and if they fall off the ladder and manage to land on their feet, they might just fracture their heel bone!

Calcaneal fractures are high-energy injuries, meaning that there needs to be a large force to create a fracture. If you think about it, falling off a ladder and landing on your heels creates a large force, as the entire weight of your body crashes into the concrete! Another common mechanism of injury for calcaneal fractures are motor vehicle accidents; another high-energy pattern. Therefore, patients who suffer from a calcaneal fracture must be evaluated fully for other injuries and fractures created during this force. The most commonly associated injury (although not common at all) is a lumbar spine (lower back) fracture. The force into the calcaneus tends to travel up the body and compacts the lower back making it more susceptible to injury.

If you have fallen from a ladder recently and suspect any kind of lower extremity injury, it is important to see you Podiatrist! They can evaluate you, take x-rays and rule out a fracture if you’re suspecting one. If there is a fracture present, they can initiate treatment as soon as possible to get you on the road to recovery! Symptoms that one might notice include severe pain! In addition there may be a distinct “black-and-blue” mark extending from the heel into the arch of the foot. As you know, we Podiatrist’s have names for everything, and call that “black-and-blue” a Mondor’s sign. In addition you will have difficulty moving the foot up and down at the ankle joint and pain with moving your foot inwards and outwards. A comparison of your feet from behind will reveal a slightly wider heel/foot on the affected side when compared to the non-affected foot.

Once you have been evaluated, any other injuries to the body have been ruled out, and x-rays confirm the diagnosis of a calcaneal fracture, the decision then becomes whether surgery is indicated or not, in order to repair the calcaneus. The answer to this question and the recommendation that your Podiatrist will make will be largely based on the location of the fracture, how far the pieces of the fracture are away from where they belong and if the Subtalar joint (the one that sits underneath the ankle) is disrupted.

In the best-case scenario, the fracture will be minimally displaced and the Subtalar joint will be unaffected, sparing you from surgical correction. In this instance, you will need to be casted for 6-8 weeks with crutches to avoid that any weight is put onto the affected foot. After those 6-8 weeks, when healing can be confirmed via x-ray, you will slowly be transitioned into a walking cast and finally back to a supportive sneaker.

In the worst-case scenario, the fracture will be largely displaced and the Subtalar joint will be severely affected, indicating surgical correction for realignment. The goal of surgical intervention is to repair the Subtalar joint with the hope that the height of the calcaneus can be regained and normal function of that joint can be restored. In order to accomplish this, a metal plate with several screws will be inserted against the heel bone to bridge the area and allow for healing in the corrected positioning. The length of time that you will be casted and non-weight bearing with crutches is closer to 12 weeks, again with transition to a walking cast and finally backs to a sneaker over the next several weeks. The treatment course for a severe fracture like this is about 6 months until you are able to return to normal activity, while the long-term effects last a lifetime.

Patients who suffer calcaneal fractures where the joint is involved, typically require an additional surgery down the line. The indication for this surgery is post-traumatic osteoarthritis, which we discussed over the last several weeks. PTOA is virtually impossible to avoid with this type of fracture pattern, but the initial surgery is important in managing PTOA in the long-term. It has been reported that patients who have initial reduction of their calcaneal fracture as indicated, do better down the line with managing their PTOA and although they end up having a joint fusion (a joint that will no longer move) they are more pain-free than their counterparts!

Scope it out!

Last week we reviewed the topic of Post-Traumatic Osteoarthritis. We defined the condition of PTOA as an arthritic condition that occurs within a joint sometime after the joint has been injured. Proper realignment of the initially injured joint helps to cut down on the occurrence and progression of PTOA, but sometimes it is inevitable!

There are several injuries, specific to the lower extremity that are infamous for causing PTOA, and they are as follows:

- Ankle fractures: PTOA in the ankle joint

- Heel bone fractures: PTOA in the Subtalar joint (the joint just below the ankle)

- Midfoot fractures: PTOA within the joints across the middle of the foot

This week, I wanted to focus on Arthroscopy as a treatment modality for PTOA in the ankle joint, following an ankle joint fracture. Arthroscopy is a procedure that utilizes a small camera to access and view the joint on a larger monitor, while allowing the surgeon to “scope” the joint and remove debris from the joint space. The end result and goal of Arthroscopy is to decrease the patient’s joint pain secondary to PTOA and to allow the joint to glide more easily through its typical range of motion.

When you suffer from PTOA, the joint becomes clouded with debris coming in the form of lose cartilage pieces, or in the form of synovitis. Synovitis describes inflammation of the “joint synovium;” a.k.a. the joint fluid that helps with easy gliding of the joint surfaces. Each of these components leads to painful range of motion in patients, thus eliminating or decreasing their presence within the joint space, through Arthroscopy, can be very beneficial!

The joint will be prepared with a distraction device, meaning an external device will be applied to both your leg and foot, with a gentle pull placed on each side, to increase the ankle joint space. This allows for easier insertion of instruments and for better visualization of the joint damage, so that debris is not missed during the procedure.

Local anesthetic will be injected into the ankle joint, with continual sterile saline flushing through the joint space during the procedure. The saline is important to create a “fishbowl-like” appearance of the joint, essentially floating the pieces of debris inside the joint that might otherwise adhere to the joint surfaces making it difficult to remove them.

The typical approach to Ankle Arthroscopy is from the front of the leg through two small incisions, measuring about 1cm in length. A camera will be inserted into one of the incisions entering the ankle joint capsule. In the other incision, a small cannula (hallow tube) will be inserted, which can be used to feed surgical instruments into the joint, helping to clear debris. A small ‘burr’ is the typical instrument of choice used by surgeons performing these procedures. The burr rotates back and forth eating debris as it is moved around the joint. Envision Pac-Man!

Post-operatively you will have two sutures in place, one over each of the small incision sites. Depending on surgeon preference, you will be placed in am immobilization device and will be required to remain non-weight bearing until your first follow-up appointment. Physical therapy is often initiated in patients who undergo Ankle Arthroscopy to help strengthen the muscles surrounding the ankle joint while improving joint function and getting you back on your feet, with range of motion to the ankle joint that is much less painful than prior to your “scope!”

There are risks to any procedure, although the risks of arthroscopy are minimal and rare. However, you should discuss all options for treating your Ankle Joint PTOA with your Podiatrist prior to any surgical intervention.

Another Useful Tool from BioMedix!

Last week we discussed PAD and the non-invasive vascular studies that can be completed in our office to help with diagnosing PAD. Through the BioMedix Collaborative Care Network, communication between your medical team can be facilitated. Chronic Venous Insufficiency (CVI) is another vascular related problem (covered on the BioMedix Website) that non-invasive vascular studies can help to diagnose, but it differs from Peripheral Arterial Disease in its location within the body’s blood vessels. As the name implies, CVI is a condition that results from damage to the veins or venous flow within the body, where as we learned last week, PAD is disease of the arteries.

Veins located throughout the body are responsible for bringing blood from locations furthest from the heart back up to the heart, for recycling and re-oxygenation by the lungs. This prepares the blood to again circulate through the body and carry oxygen out to the tissues. Located within the bodies veins are tiny one-way valves which when the blood is being transported back up to the heart, help pump the blood upwards while closing off with each beat of the heart to prevent backflow of the blood with gravity. When those valves become damaged, patients suffer from Chronic Venous Insufficiency, where the body has difficulty pumping blood through its veins back up towards the heart.

Patients will slowly notice an onset of symptoms including painful, swollen and “heavy feeling” legs. They will notice that their legs begin to feel tired or restless at the end of a long day, which is something they have not experienced before. In addition, patients may start to notice varicose veins and veins bulging through the skin as the pressure building up within them predisposes them to enlargement.

Other associated symptoms and conditions may include skin discoloration, dry scaly skin along the legs and feet and breakdown of the skin if the buildup of extra fluid in the legs becomes too great. Breakdown of the skin typically presents in the form of a “Venous Stasis Ulceration,” which basically means what we’ve been saying: the ulceration is caused by blood located within the venous system of the body that is stuck in the legs and leads to ulceration.

Risk factors for the development of CVI are varied, but some can depend largely on hereditary and the nature of the patient, meaning those that have a family history of CVI or are women over the age of 30 are at a greater risk for development. In addition, patients with a history of blood clots, multiple pregnancies or who do lots of heavy lifting and endure long periods of standing also have an increased risk.

If you present to your Podiatrist with a variety of the risk factors and symptoms consistent with Chronic Venous Insufficiency, your diagnosis may be made by clinical examination alone. However, it is important to undergo Vein Studies to help rule out any larger problems, such as blood clots, in addition to selecting the most appropriate treatment regimen.

We mentioned last week that Advanced Footcare Centers LLP collaborates with BioMedix through a Collaborative Care Network, where vascular testing can be completed and communication can electronically occur between your medical team (Podiatrist, Primary Care Physician and Vascular Surgeons). In addition to including testing for Peripheral Arterial Disease, BioMedix also collaborates on testing and treating Chronic Venous Insufficiency.

The most accurate test is called a Venous Duplex Ultrasound. The test takes an ultrasonic picture of the veins in the body to detect any acute or chronic blockages in addition to evaluating the status of your veins one-way valves. Once any acute blood clot has been ruled out and Chronic Venous Insufficiency has been diagnosed, there are a variety of treatment options available. Some treatments can be done by you at home, such as maintaining a healthy diet and exercising regularly to increase the competency of your legs muscle pump to help bring blood back to the hear easier. Compression stockings are often encouraged for patients without any history of congestive heart failure and for those patients that stand for long periods of time, as the compression will help the legs bring blood back up towards the heart rather than becoming stuck in the legs. Medications such as diuretics can be used to decrease some of the fluid build-up, but as always, before any of these treatments are initiated, consult your Podiatrist and your Primary Care Physician.

For more information on Chronic Venous Insufficiency, please click on the link below, which will direct you to the BioMedix Collaborative Care Network!

http://www.biomedix.com/patients/CVI_patient_resources.asp

Non-Invasive Vascular Studies: Take One!

Several months ago I blogged about Peripheral Arterial Disease (April 23, 2010: The Triad That Leads to P.A.D.), which is a disease of the circulatory system where blood flow to the periphery of the body, mainly the legs, is compromised or blocked secondary to a build-up of plaque within the vessel walls. The major risk factors that increase a patient’s chances of developing plaque build-up and subsequent Peripheral Arterial Disease are three: High Blood Pressure, High Cholesterol, and Smoking. Diabetes can also contribute to the disease, but keep in mind that although Peripheral Arterial Disease is commonly seen in the diabetic patient, it is not limited to that patient population alone.

In that blog it was mentioned that non-invasive Vascular Studies could be completed when pulses in the feet were non-palpable to your Podiatrist. These non-invasive tests can help to determine the amount of blood flow, while predicting blockages or occlusions within the main vessels carrying blood to the legs, feet and toes.

The first and most basic test that is typically ordered is called an “Ankle-Brachial Index,” or ABI as it is referred to in the medicine world. This test is performed using a simple blood pressure cuff, first applied around the arm to determine the blood pressure in the arm, and next applied to the calf to determine the blood pressure in the leg. The test is performed with the patient lying flat on a bed, usually on their back and will only take a few minutes to perform. The test is also painless, although some patients may experience minimal discomfort with inflation of the blood pressure cuff, which will be relieved upon deflation.

A second test, and one that is typically performed in conjunction with an ABI, is called a Pulse Volume Recording (PVR). As the heart beats, blood is “pulsed” throughout the body and when measured in the lower extremities by the PVR test, the values obtained can help indicate areas where the blood flows best and areas where there may be disruptions in blood flow. The test is performed by applying multiple blood pressure cuffs at intervals down the legs, and jas with ABI testing; it is a painless exam and is tolerated well by most all patients.

Together the information obtained in the ABI and PVR tests can help determine how well blood is flowing down into the legs and will indicate if there is narrowing or blockage of the vessels in any areas. It will also help determine how progressed your Peripheral Arterial Disease is and will guide treatment of the disease specifically for you!

At Advanced Footcare Centers, LLP Ankle Brachial Indices and Pulse Volume Recordings are completed in the office and your information is electronically sent via BioMedix PADnet, through our Collaborative Care Network. The Collaborative Care Approach ensures that the appropriate physicians managing your care, including a vascular surgeon and your primary care physician, all have access to the information obtained via these tests. Thus, they can work together on finding the best solution to managing your early or progressed Peripheral Arterial Disease.

For more information on the Collaborative Care Network with PADnet and BioMedix, of for more information on Peripheral Arterial Disease, click on the link below. If you have questions or concerns about the blood flow to your extremities, contact your Advanced Footcare Center Podiatrist today!

http://www.biomedix.com/collaborative_care_model.asp

Fun for the Podiatric Surgeon; Not So Much Fun for the Patient!

As a human being, I never want to see anyone get injured, but as a medical professional, if no one ever did, I would be out of a job! So sometimes, injuries are fun to see, as it presents a challenge for determining the best option for treatment. About a week ago a patient came into the Emergency Room with a Type II Gustillo Anderson fracture of the 1^st, 2^nd and 3^rd toes after a car jack slipped and landed onto his foot. (Hopefully you’ll understand what all that means by the conclusion of today’s Blog) It wasn’t much fun for the patient, and I felt bad for the guy as he was a really nice man, but getting to treat his injury was fun!

An open fracture is any fracture that is accompanied by a break in the skin in the area of the boney fracture. The broken bone does not necessarily need to be protruding from the skin, but it often will be. These types of injuries are not exclusive to the lower extremity, but when found there are typically associated with high-energy injuries. Meaning any injury where there is a strong force or impaction as would be the case in falls from a height or motor vehicle accidents for example, or in the case of this patient, direct force to the foot from the car jack.

There are two main ways to look at an open fracture: was the break in the skin caused by something from the outside penetrating inward, or was the break in the skin caused by a bone from inside the body pushing outward? In terms of treatment and managing the fracture site, the answer to this makes little difference, but if the break in the skin was caused by something outside (like a nail or bullet) penetrating inward, you would want to consider whether the patient has an updated tetanus vaccination and what bacteria are commonly associated with the type of object that has penetrated the skin.

If you haven’t picked up on it yet, in the medical profession we love to classify things! Some of our classification systems make little sense, but it gives us a way to communicate with our colleagues in a succinct manner. For open fractures, the classification system used most often is the Gustillo and Anderson Classification. It evaluates open fractures based on: soft tissue coverage and injury to blood vessels, muscles and/or nerves. The classification is as follows:

Type I: An open fracture less than 1cm in size with little soft tissue involvement and no crush of the bone.

Type II: An open fracture that is greater than 1cm in size with minimal soft tissue damage.

Type III: An open fracture that is greater than 5cm in size with extensive soft tissue damage including damage to muscle, nerve and blood vessels.

Open fractures are typically surgical emergencies from a Podiatric Medicine standpoint, meaning we would like to take the patient to the Operating Room within the first 24 hours. Type III injuries would be taken to the operating room sooner than a Type I injury. The goal in taking these patients for a surgical procedure is to clean out the soft tissue eliminating as much dirt and bacteria as possible, to reduce/realign the fracture fragments into their correct “pre-injury” position and to close the skin if possible preventing further infection. If all the goals of surgical intervention are met, it will help decrease the risk of further tissue damage as well as decrease swelling, pain and bacterial spread, getting the patient on the road to recovery!

If we revisit the patient I saw in the ER last week, we can recall that he had a Gustillo-Anderson Type II injury. If we refer to the classification system, we know that the open part of the injury along the digits was larger than 1cm with minimal soft tissue damage. His injury was an “outside to in” type injury, but luckily, the car jack did not break through his shoe, thus there was no foreign body present. He was given a broad-spectrum antibiotic (to cover the most common types of bacteria) and was taken to the OR the following day. One of the bones in the big toe suffered a crush injury and had very little soft tissue coverage, meaning it was in many small pieces and would have been difficult to approximate the skin edges, thus the bone was removed. The bones within 2^nd and 3^rd toes had one fracture line each, so they were reduced and the soft tissue coverage over them was adequate, thus they were closed.

Open fractures are not something we see on a daily basis, and certainly can be detrimental to the patient depending on the severity of injury, but they do provide a welcomed challenge to the Podiatric Surgeon!

For more information on foreign body injuries, refer to our Blog from June 28 entitled: Think Twice Before Kicking Off Those Summer Shoes!

Should Little Girls Wear High Heels?

This past weekend I was at a wedding and just before the bride entered, the cutest 3 year old girl in a white “frilly” dressing, with a green sash and sparkly high-heels walked down the isle spreading flowers in her path. I should have been “oohing and ahhing” at how cute she was, but I couldn’t get over the fact that she was wearing heels!

Several months ago a featured segment on a National Morning News broadcast, addressed the issue of girls from as young as 3 years old wearing high heels. It was mentioned in the segment that these young girls are still undergoing developmental changes, and wearing heels could have implications on proper growth. That is in fact true! The last bones in the foot to solidify, changing over from cartilaginous material to solid bone can take place up to the age of 18 years. Wearing heels at such a young age could have serious implications on growth!

The mechanics of heels are many. They can:

1. Increase pressures on the ball of the foot

2. Increase ankle instability leading to injury

3. Tighten the heel cord creating changes in gait including "toe walking"

4. Induce changes on growth plates, which don't close until late in the teen years, causing developmental complications.

5. Predispose an already destined foot type toward the development of bunion and hammertoe deformities.

Aside from injury to your child’s foot, which should be avoided at all costs, tightening of the heel cord most certainly creates changes in gait including “toe walking.” However, that’s not the only problem that a tight heel cord can induce. If you remember, throughout several previous blogs, including the ones on plantar fasciitis and retrocalcaneal exostosis (“pump bump”), tightening of the musculature in the back of the leg, which is essentially the heel cord, can contribute to multiple foot issues and pain both in the back of the foot and on the plantar surfaces of the foot.

We’ve talked about the mechanics of bunion deformities before and that your foot-type predisposes you to the development of bunions and in fact, hammertoes, all of which proper and supportive shoe gear can help to prevent or slow the progression of. If you’re child wears heels from the age of 3 and has a foot type that pre-disposes them to bunion and hammertoe deformities, they will more than likely develop these deformities much sooner in life, with correction necessary in their early teen years.

Although heels may look "cute," there are plenty of flat shoes out there these days that are also cute! Kids love sparkly and 'jazzy' things, so why not find some sneakers or ballet flats that fall into that category? It simply isn’t worth the risk of injury, developmental complications or the formation of bunions and hammertoes to wear high heels for the fun of it.

In the event that your child wants to wear heels for special events, that’s okay. It is, however, recommended that you limit wear to 4 hours or less and choose heels with a wider toe box and a more stable heel. This will help prevent crushing of the toes as well as help decrease the instability typically associated with a ‘skinnier’ high heel.

Laser Therapy for Treatment of Onychomycosis: Fact or Fiction?

Back in April, in our Blog entitled: “Achoo! The Common Cold of the Feet” we discussed in detail, fungal nail infections. Much discussion, in both the Podiatric and Dermatologic communities surrounding Laser Therapy Treatment for onychomycosis (fungal nail infections), has surfaced in recent months and years. The topic of laser therapy was briefly mentioned in April’s blog, but this week, I’d like to provide you with a little more insight as to what Laser Therapy aims to do in order to treat fungal nail infections, and if it will be effective or not.

Lets quickly review the basics: what is onychomycosis? Onychomycosis (on-EE-ko-my-KO-sis) is a fungal infection of the nail that can be caused by 3 types of fungus: non-dermatophytic molds, yeasts, and dermatophytes. The most common infective "bug," accounting for 70% of all toenail infections, is a dermatophyte by the name of T. rubrum. The names, none of which are important, mean very little in relation to treatment modalities that can be used. It is, however, important to know that the types of fungus causing toenail infection thrive in moist environments, therefore keeping feet clean and dry helps prevent infection by one of these "bugs." It is also important to clean community showers frequently with chemicals like bleach, killing any organisms living on the tile. Wearing shower shoes, in situations where you are not responsible for cleaning, is also a wise decision!

When the organism gets into the bed of the nail and/or the nail matrix (the tissue from which the nail grows), your nails will become thickened, discolored, and often brittle. Patients experience associated pain with fungal nails due to increased thickness which causes the nails to become pressed up against the inside of shoes. Nails become difficult to trim at home and embarrassment in open-toed shoes or sandals is imminent!

Treatments, as they are currently available, do very little for long-term cures. Several pills and nail lacquers do help the appearance of nails and decrease thickness. However, they are not without their side-effects, and when use of these medications are discontinued reoccurrence of fungal infection is likely is 70% of patients. Over the counter methods such as mouthwash, Vicks Vapor Rub and Vitamin E lotion seem to benefit in decreasing thickness, but long-term research studies have yet to be conducted to determine the effectiveness of such remedies for providing a cure. My guess would be that their cure rates would be similar to oral and topical prescription medications, as fungal nail infections are typically VERY difficult to treat. The problem with treating and curing fungal infections long-term is seeded in the way the fungus manifest within the nail, making it very difficult to get to the source of the infection and kill it from the inside out.

The science behind laser therapy for treatment of onychomycosis is still relatively new, unknown and lacking research! The Patholase "Pinpoint Foot Laser" featured in the news recently, although approved by the FDA for use in Dentistry and Soft-Tissue cutting, is not currently FDA approved for the treatment of Onychomycosis. The initial study Patholase conducted to support its "off-label" use for the treatment of toe-nail fungus centered around 16 patients, which is never large enough of a research pool to deem something effective and safe for continued use. The price is astronomical, mentioned to be close to $1200 per session to have all 10 nails treated, with no safe bets for complete resolution of fungal infection.

The Noveon Laser, by Nomir Medical, is a laser therapy device currently undergoing FDA Clinical Trials for approval of its use in treating Onychomycosis. It holds more promising evidence than Patholase in its effectiveness in treating and possibly curing fungal nail infections. At this time, Nomir Medical makes no claims that treatment with its laser is more or less effective than the currently available oral and topical medications and admits that further clinical trials need to be conducted.

In short, fungal nail infections are extremely difficult to treat and only time and continued research will tell if a long-term cure is a possibility, especially in the realm of Laser Therapy. The best option available today is to try one of the currently approved methods, and once treatment has concluded, prevention of reoccurrence becomes key!

For more on prevention of recurrence, check back to Aprils blog!

No More Vaseline!

The most common response from my patients, when asked about what agents they use to moisturize their legs and feet is: Vaseline. It is a complete myth that Vaseline moisturizes skin, but it does a very good job at creating that façade!

The skin is composed of three main layers: the epidermis, dermis and subcuticular layers.

Epidermis: the upper/outermost layer of skin, which is obviously the most visible layer and itself has 5 distinct layers. It acts as the initial barrier to protect the body from invasion by bacteria and other foreign materials and substances. Its main cellular component is called a “keratinocyte,” which makes its way from the lowest layer of the epidermis to the top layer of the epidermis. By the time keratinocytes reach the top layer of the epidermis, a.k.a. the surface of the skin, these cells are dead and thus, dry skin!!

Dermis: the second layer of skin, that is not visible to the eye, and is made of up two distinct layers. The dermis plays a very important role in the formation of hair follicles and sweat glands, helping to regulate the temperature of the skin and body. It also contains blood vessels that supply the skin.

Subcuticular: the deepest of the three layers that make up the skin. It consists mainly of fat cells that store energy, varying in thickness depending on what area of the body the skin is covering.

The skin has a very distinct cycle of growth, development and death (dry skin). The keratinocytes (principle cells in the epidermis) take 8-10 weeks to rise from the bottom of the epidermal layer to the top of the epidermal layer. As I mentioned before, once they reach the top layer, they are no longer “living cells” and appear as dry skin. To keep the skin healthy, this top layer of non-living Keratinocytes needs to be removed, and moisture put in its place. Vaseline neither removes non-living keratinocytes nor imparts moisture into the skin. Therefore, it is not a good option for “moisturizing,” but because it seals in any moisture that might already be present in the skin, it does a very good job at ‘pretending’ to moisturize!

So what is a good option for moisturizing the skin? The answer: it depends on the condition of the skin. For mild conditions, imparting moisture into the skin may provide adequate results, but in more severe conditions of dry skin, keratinocytes need to be removed so that the moisturizing agents can reach healthier layers of the skin. Therefore combinations of desquamation agents (used to remove keratinocytes) and moisturizing agents are best!

In a patient with mildly dry skin, moisturizers alone (substances that impart moisture into the skin), can work fairly well and can be found over the counter at your local drug store. Some good options include: CeraVe, Eucerin and Vaseline Intensive Care.

In a patient with mild to moderately dry skin, there are prescription lotions that will help remove some of the keratinocytes on the surface of the skin as well as impart moisture. These agents usually contain an ingredient called Lactic Acid. A commonly prescribed lotion for mild to moderately dry skin is called AmLactin.

For patients who have severely dry skin, prescription strength lotions can be given to remove most of the keratinocytes on the surface of the skin in addition to imparting moisture. These agents contain an ingredient called Urea. Examples of such lotions include Umecta and Keralac.

It is important to have nice healthy skin to prevent breakdown or ulceration, in addition to helping the skin maintain its functions in protecting from foreign substances and body temperature regulation. The best time to apply moisturizing agents is within the first two minutes after you’ve showered, as the pores are the most open during that time interval and the moisturizer can penetrate into deeper layers of the skin.

If you’ve attempted over the counter lotions, such as the ones mentioned above without success, speak with your Podiatrist about trying a prescription moisturizer that will help remove keratinocytes. You may see healthier looking skin in no time.

No more Vaseline!

“The Leg Bones Connected to the, Knee Bone…” by Tendons!

Tendons are tough, yet flexible bands of fibrous tissue that connect a muscle to a bone. Such tendons are responsible for transmitting a muscle contraction to the bone in which it connects, invoking movement. The most well know tendon in the body is the achilles tendon. This tendon arises from two muscles in the posterior compartment (calf) of the leg and attaches to the heel bone (calcaneus). When either of the two muscles from which it arises contract, the achilles tendon pulls on the heel bone and causes plantarflexion of the foot at the ankle joint (movement of the toes in a downward direction). The tendon itself provides no contraction and ultimately no strength to the movement, but its integrity is important for normal joint functions. Without the achilles tendon specifically, plantarflexion of the foot would be very challenging, if not impossible! This would be the case for any joint motion, as without tendons, muscles cannot exert their pull on a bone.

Tendons can rupture (completely tear) at their “watershed” areas, typically as the tendon is bending around another anatomical structure along its path. These areas are best described as the weakest points of the tendon due to their poor vascularity (blood supply). Although we are not discussing tendon ruptures today, keeping these areas in mind is helpful when discussing tendonitis, as these same areas are also at a higher risk for development of tendonitis.

Tendonitis is irritation and inflammation of a tendon that is most felt by the injured individual when its corresponding muscle is being contracted. The presence of inflammation prevents the tendon from “gliding” as it should, when attempting to transfer the muscle contraction to the bone, resulting in pain. Inflammation within the tendon is usually secondary to over-use, and is most commonly seen in the novice individual, but can also be seen in professional athletes. It’s the kind of injury, that although attributed to over use, the occurrence in a well-trained athlete is peculiar and has no definitive explanation other than over use!

Whatever the etiology of tendonitis in an athlete, pain and discomfort is a very real thing. The athlete will most likely suffer from tendonitis in a tendon they use frequently (eg. tendons of the elbow’s in a quarterback; the achilles tendon or lower leg tendons in centers etc), and thus with repeated movement and contraction of the muscles to which that tendon is responsible, pain with motion in eminent. Pain directly over the tendon and along its course into the bone, in addition to crepitus (a “crunchy” feeling) within the tendon is diagnostic for this condition. X-rays typically will not show tendonitis, as tendons are not dense enough to show up on x-ray, however and MRI is much more sensitive for detecting the inflammation in and around the tendon. Is an MRI necessary? Not always, but will typically be ordered for athletes who fails to improve after several weeks of treatment.

Treatment is much the same as treatment of muscle sprains and turf toe, which we’ve reviewed the past two weeks. RIICE: Rest, Ice, Immobilization, Compression and Elevation. Although in this situation, rest is the most important thing. It will give the tendon a chance to heel and for the inflammation to decrease. Again, over the counter anti-inflammatory medications and/or tapered systemic steroids will decrease local tendon inflammation, while injections are not typically utilized for tendonitis. Depending on the location of the tendonitis, steroid injections may be associated with an increased risk of tendon rupture.

Risk of increased pain and even rupture is associated with this type of injury if not treated properly, or if the inflammation isn’t given sufficient time to subside before a return to activity. Therefore, a slow but important recover, with physical therapy, and most importantly rest cannot be expedited! It may take several weeks for a return to normal activity.

As old Greek Mythology proclaims, the heel was the most vulnerable part of Achilles’ body, and thus, it was his weakness and ultimately an injury in that area that killed him. Although this injury will not kill a professional athlete or any athlete for that matter, tendonitis in the achilles and other tendons of the body, can be painful and temporarily debilitating!

Strains, Sprains and…Automobiles?!

This month we’re taking on the topic of commonly suffered injuries by our most beloved National Football League players. As mentioned last week, it’s hard for us to be sympathetic towards players who suffer injuries we think they are capable of playing through. The hope is that with a little more understanding of their injuries, our sympathy might go a stitch further…although probably not too far!

Last week we discussed turf toe including the limitations and long-term implications this injury can have on a professional athlete if not treated properly. As promised, this week we will be discussing muscle injuries! In order to do so, there are a few distinctions that must first be made.

1. A strain describes an injury to a muscle. Essentially a strain describes a series of “micro-tears” in a muscle belly, which may also be referred to as a “muscle pull.”
2. A sprain describes an injury to a ligament. Ligaments are bands of tough (fibrous) tissue that connect bone to bone and provide support to joints (ankle, knee etc) preventing motion of the joint in an abnormal direction. Sprains will not be the focus of this week’s blog.
3. A torn muscle describes a partial or complete tear that is typically much more debilitating to the athlete than a strain would be.
4. A ruptured muscle is also a torn muscle, but only refers to a complete tear in the muscle and typically indicates shortening of the muscle fibers, making repair and recovery much more difficult.

Now that we’ve clarified those few terms, lets discuss how an athlete, who may be among the most “in-shape” individuals, suffers an injury to their muscle. A muscle becomes strained, torn or ruptured when a sudden, extreme force is applied to the muscle and stretches the muscle fibers beyond their capacity. This may occur by a direct force to a joint for which the muscle or the muscle tendon may cross, or may also occur with an abnormal motion of the muscle in a direction in which it is not designed to act. No matter which mechanism occurs, if you’ve ever watched an athlete suffer a muscle injury, you will notice that they immediately grab the area of injury, indicating the instant pain and inflammation that occurs!

To differentiate between a strain, torn, or ruptured muscle, the best and most definitive study would be an MRI (Magnetic Resonance Imaging). It is able to capture defects in the muscle belly in addition to inflammation in and around the area of complaint. However, testing the strength of the injured muscle compared to the healthy side can also provide an indication as to the extent of injury and help classify it as a strain, partially torn or ruptured muscle.

Initial treatment for a muscle injury includes ice and rest, in addition to anti-inflammatory medications. After several days of this, gentle and passive stretching (meaning by a physical therapist and not by the athlete) can be initiated. This stretching will prevent the muscle fibers from healing in a shortened position, which would predispose the muscle to becoming re-injured. The best indicator of healing is the amount of pain, or the decrease in pain the athlete is suffering from. However, an increase in muscle strength from initial examination after the injury is also indicative of healing. In the most benign of muscle injuries (strains) the athlete can be back in action within two weeks. However, with a torn muscle (one that is not completely ruptured) this process can take much longer, sometimes more than a month! In the worst-case scenario where the muscle has been ruptured, surgical repair is often recommended, for which recovery can be months long!

As with most things that we’ve discussed over the last year, prevention of muscle injuries provides the best scenario for the athlete and for his/her supporters. Of course, athletes must focus on flexibility and strength through training, but proper stretching and ensuring adequate warm-up before and cool-down after activity will also help prevent muscle injuries. It is important that at the first sign of possible injury, the athlete be evaluated by their “on-staff” Podiatrist, Orthopedist or Athletic Trainer to prevent further or more detrimental injury! Early evaluation can make the difference between a simple strain, or a strain that turns into rupture.

Turf Toe

With the advent of football season starting this past weekend, I thought it appropriate that we try to “tackle” common injuries suffered during the season. As some of you may know, when players in the NFL are injured it completely messes up our Fantasy Football seasons and we quickly scramble to pick up “free agents.” Aside from our frustrations, however, it’s the players who are suffering from ankle injuries, muscle sprains, tendonitis and so forth. Understanding some of their conditions might provide us with a small amount of sympathy for the ridiculous amount of money they’re making to sit on the sidelines!

Professional athletes are considered to be in tip-top shape compared to the average citizen, and many people wonder how, being in such great shape, they still manage to injure themselves. I can assure you, although some injuries occur secondary to poor preparation most occur secondary to over-use, direct impact, or abnormal force vectors through the body.

This week I would like to discuss Turf Toe. It seems like an ambiguous diagnosis, but it is a real diagnosis with those most frequently afflicted being athletes that play on turf surfaces. The actual injury is a disruption of the plantar ligaments (those underneath) the big toe secondary to hyperextension, or excessive bending of the toe upwards in relation to the foot.

The injury occurs when the athlete’s cleat gets ‘stuck’ in the turf surface while the body is moving in a forward direction. This motion forces the big toe to extend, abnormally, before the cleat can release itself from the surface. This hyperextension can induce an overstretching of the plantar ligaments, a partial tear, a complete tear, and even cause damage to the big toe joint if it becomes compressed during the injury. Almost immediately pain becomes evident to the player, but professional athletes tend to play through pain until it’s absolutely unbearable. However, this pain is usually accompanied by swelling and difficulty in bending the toe, realized when the athlete removes his or her cleat after a game.

The tenants of any injury apply to treating Turf Toe: RIICE: Rest, Ice, Immobilization, Compression and Elevation. Rest and Immobilization will prevent further injury to the plantar ligaments in addition to giving them a chance to repair themselves. Ice, compression bandaging of the toe and elevation will help decrease swelling and subsequently decrease pain to the joint. Of course, non-steroidal anti-inflammatory drugs such as Ibuprofen can be utilized to decrease pain and help control inflammation as well. Athletes are typically encouraged to keep off their toe/foot for at least 3 days, after which partial weight bearing in a rigid soled shoe, to prevent motion at the joint, can be attempted

It is always wise, when a Turf Toe injury is possible, to be evaluated by a Podiatrist. X-rays can help rule out damage to the joint and physical therapy will help get the athlete back to their game in no time! It is likely that with return to activity, protection of the toe will be exercised through taping and shoe accommodations to keep motion to a minimum. Obviously, depending on the extent of damage, more time away from the game may be necessary to allow for adequate healing, but at the professional level, those athletes are looking at a maximum of three weeks on the sidelines. Too early a return to activity can lead to further damages to the joint, including arthritis and eventual loss of motion, so caution should always be exercised!

Next week, I’ll be discussing muscle pulls and tears including those most commonly suffered in professional athlete: the hamstring, and achilles tendon.

Think R.O.D.

Over the last three weeks we’ve been discussing the most common complications to affect the diabetic patient in the lower extremity. Diabetic neuropathy with circulatory compromise and increased plantar foot pressures all contribute towards an increased risk of diabetic ulceration in such patients.

I’ve given you many helpful tips for decreasing your risk of developing each of those three complications, and again I’ll reiterate that prevention is your best option! However, despite your best efforts, if you do develop a “neuropathic ulcer,” you will be facing an uphill battle in getting that ulceration to heal. This week I hope to help you identify signs and symptoms of an ulceration that needs immediate treatment, increasing your chances of healing that area quickly.

First and foremost, you should understand what I mean when I say “neuropathic ulcer:” this is an ulceration found in an area of the foot where you lack sensation such that the causative agent (whether a foreign object or friction) went undetected by you. Treatment begins with recognition of the ulceration at home during your daily foot checks. Once you’ve identified a break in the skin or ulcerative area, you should immediately call your Podiatric Physician for an appointment. This last step is very important, no matter how large or small the area of ulceration may be, because these wounds have a history of quickly deteriorating.

Now, if the area in question is discovered on a Friday after your Podiatrist’s office has already closed for the weekend, there are some signs and symptoms you need to be on the lookout for. These signs/symptoms will help you determine if you need to seek immediate treatment at an Emergency Room, or if you are able to wait it out until Monday. In deciding this, think ROD: Redness, Odor, Drainage.

R = Redness: If the skin surrounding the ulceration is extremely red, hot and swollen, this is a cause for concern. Even more emergent is recognition of red “streaking” from the area of ulceration up towards the core of the body. Streaking is a sign of infection that is penetrating the lymph system and needs immediate attention. As an aside, if you are having any symptoms of a systemic infection, such as fever, chills, nausea or vomiting, you are also in need of immediate treatment.

O = Odor: If the area smells fruity or has an unbearable odor associated with it, this may be an indication of local infection across the base of the wound. If this is the only symptom, what you should do is clean the area with warm soap and water, dry it completely and place a clean dry bandage over the area, to be changed each day until you’re able to see your Podiatrist. If this odor is associated with systemic symptoms, excessive redness or streaking and alarming drainage, you are in need of immediate treatment.

D = Drainage: If there is green or thick yellow drainage coming from the area, typically associated with an odor, you need to be seen immediately. This is a definite sign of local infection, and one that may spread quickly, so it’s important to seek medical attention.

As a disclaimer, if you are unsure that your wound meets any of these criteria, my advice would be this: go to the Emergency Room. It’s better to be reassured that everything is okay than to miss an ulceration that’s quickly deteriorating. In addition, if the ulceration seems to be changing for the worse and digressing quickly, you should also seek immediate treatment.

Decreasing You Risk of Ulceration

Over the last two weeks we’ve been discussing diabetic complications of the lower extremities; an important topic in terms of raising awareness and helping you to prevent or slow progression of such complications. This week, I want to focus on the function of the foot in the diabetic population and again, how prevention is your best option for decreasing your long-term risk of complications.

In the diabetic population, equinus is the overwhelming commonality between patients suffering from plantar wounds associated with diabetic neuropathy. Equinus, to explain it simply, is a lack of dorsiflexion, or ability to raise the foot at the ankle joint past 90 degrees (neutral position). The ankle and foot function best in gait when dorsiflexion at the ankle is at least 10 degrees past the neutral position. When this is decreased, excess pressure is placed on the plantar forefoot throughout gait, and increased pressures automatically lead to an increased risk in ulceration.

Patients develop equinus from a lack of flexibility in the musculature of the leg, namely the calf. Whereby, dorsiflexion becomes decreased because it is those muscles in the calf that are responsible for lifting the foot above that neutral position during gait. If those muscles are tight or contracted, which occurs in patients who don’t stretch or exercise on a regular basis, equinus and increased forefoot pressures result.

Increased pressures in any area of the foot create a major risk in the diabetic patient, and such pressures can also be induced by tight fitting shoes, open-toed sandals that rub between the toes, and areas of friction along bunion prominences or on the tops of contracted digits (hammertoes) in closed-toed shoes. The reason increased pressures are such a risk is that in places of friction, typically not felt by the neuropathic diabetic patient, a pre-ulcerative lesion may develop. The area goes undetected, unless you’re religiously checking your feet on a daily basis for new lesions (which you should be doing!), and the pre-ulcerative lesion turns into a wound.

Again, you are faced with the issue of non-healing secondary to poor circulation (which we discussed last week), such that the nutrients needed for wound healing carried by the blood have difficulty getting to the area. In addition, if you have not addressed the issue of equinus or the problem shoes that created the initial friction, you’re bound to have problems in the future, even if you’re able to heal this time around. So what can you do? Again, the answer is prevention!

There are two important ways in which you can take control of the deforming forces of equinus and increased pressures placed on the foot:
1. Stretch – By stretching the musculature in your calf and increasing the flexibility around the ankle joint (decreasing your equinus), you will greatly decrease pressure placed on the plantar forefoot and decrease your risk of ulceration. There are several exercise, that are easy to do:
a. Wall Stretch: With your feet shoulder width apart, one foot in front of the other, place your hands on the wall in front of you. Keeping the back leg straight and the front leg bent slightly at the knee, lean into the wall. You should feel a light stretch in the calf of the straight leg. Hold this for 20-30 seconds, take a 15 second break and repeat 10 times. Then switch front and back feet, so that you can stretch the opposite side. Again, hold for 20-30 seconds, repeating 10 times.
b. Heel Drop: This exercise will require a set of stairs with a railing available for balance. Place the balls of both feet on the step, knees straight and allow the heels to suspend off the step and drop down below the level surface via your body weight. You should feel a light stretch in the calf of both legs. Hold this for 20-30 seconds, take a 15 second break and repeat 10 times.
2. Invest in a pair of diabetic shoes – Especially important for those patients with diabetic neuropathy, but important for any diabetic patient. Diabetic shoes have a custom molded insert with a wide and deep toe box. The insert is made from a mold of your foot and alleviates all areas of pressure on the plantar foot. The wide and deep toe box allows the foot room within the shoe, preventing areas of friction on boney prominences. Diabetic shoes essentially alleviate all friction areas, thus decreasing your risk of pre-ulcerative areas and ultimately of developing an open wound.

As you can see, the power again remains in your hands when it comes to decreasing your risk of complications associated with diabetes! With diet and exercise, controlling your blood glucose levels, managing your co-morbidities and preventing areas of pressure in the foot, you’ll be well on your way.

Circulation in the Diabetic Patient

Patient’s recently diagnosed with diabetes are often encouraged to visit a Podiatrist for a complete lower extremity exam, but the reason for this evaluation is unknown to the patient! Podiatrists have expert knowledge in understanding the lower extremity in addition to the affects that diabetes can take on the body, and we will evaluate you and identify risk factors for increased complications in the short and long-term. As we discussed last week, diabetes is an autoimmune disease that stimulates an increase in blood sugar levels if not managed correctly. The first complication we see in the diabetic population, relative to the lower extremity, is a loss of sensation in the feet, or diabetic neuropathy. In last weeks blog, we mentioned that prevention is most important in managing this complication, and this same ideal goes with this weeks discussion on circulation to the lower extremities in the diabetic patient.

When it comes to circulation, the complications that present themselves to anyone, but especially the diabetic patient with diabetic induced neuropathy becomes the decreased flow, and subsequently decreased healing potential in the lower extremities. The circulatory system in our bodies, beginning with the heart, carries blood, oxygen and thousands of growth factors out to the organs of our body supplying nutrition to those areas. When blood flow out to the extremities decreases, as it often does in the diabetic population, healing potential deceases because those nutrients can longer reach the affected areas. Thus, with neuropathy, if an injury to the soles of the feet goes unnoticed and blood flow to that area is compromised, healing to the site of injury becomes very difficult!

Decreased circulation in the diabetic patient comes from the root of all evils: uncontrolled blood sugar levels. Long-term, uncontrolled blood glucose levels induce damage on the arteries of the body, particular the peripheral arteries (those farthest from the heart) through weakening of the vessel walls. Weakening creates strain on the vessels and often leads to their thickening or collapsing in efforts to overcome that strain. In addition, co-morbidities often seen in the diabetic patient, including high blood pressure and high cholesterol, increase damaging risks to the vessels. These other medical issues induce atherosclerosis, which is a fancy way of saying “narrowing and hardening” of the vessel walls, making it more difficult for blood to flow easily down to the feet.

At your Podiatric appointment, in addition to checking the sensation in your lower extremities, your circulation will be evaluated. If pulses are easily palpable and there are no open wounds, at that point in time you’re good to go! However, if the pulses are difficult to feel, if your feet are a little cooler than your legs and if blood flow into the toes is slowed, it will be explained to you that circulatory issues are presenting themselves. It may be that your Podiatrist will order lower extremity arterial (blood flow) studies to evaluate your flow in addition to evaluating your healing potential so that a baseline of your circulatory status can be noted. It certainly isn’t the end-all, be-all to have circulatory issues, but it simply means that you need to be more careful and as we discussed in relation to diabetic neuropathy, prevention of further circulatory issues is the best possible scenario!

The ways in which you can prevent circulatory complications are many, but first and foremost include controlling your blood glucose levels to prevent weakening of the peripheral arteries. Next, you can decrease your risks by following up with your primary care physician regularly for management of your co-morbidities such as your high blood pressure and high cholesterol. Take medications prescribed to you as directed to lower the risk of complications by these associated medical issues. In addition, maintaining a good exercise routine, even if its 30 minutes of walking three times per week, helps increase blood flow and efficiency of the heart. (Of course, speak with your doctor before starting any exercise routine.) Finally, protect your feet! Wear shoes at all times and check the soles of your feet and in between your toes daily. Catching an opening in the skin early on significantly increases your chance of healing that wound, as the longer it goes unnoticed, the longer it will take to heal.

Next week, we will discuss the biomechanics of the feet, relative to diabetes and what you can do to decrease pressure areas that lend themselves to ulceration!

A Few Reminders About Diabetes

It’s been quite a while since we tackled the topic of Diabetes, and because understanding the disease and the complications it can induce throughout the body and especially your lower extremities are so important, I want to refresh your memory. Over the next few weeks we will discuss in detail the complications seen in lower extremities and what you can do to help yourself avoid or manage these.

Diabetes is an autoimmune disease that affects the levels of glucose (sugar) in your blood. In patients with diabetes, they either don’t produce enough insulin to breakdown their daily calories, or they make no insulin at all. Whichever type of Diabetes you have, either type can lead to complications in the lower extremities.

The first complication we typically see in the diabetic population is loss of sensation on the plantar aspects of their feet, also known as Diabetic Neuropathy. High glucose levels in the blood stream tend to induce changes around the nerve coverings beginning first with the hands and feet. For our purposes, it’s best to explain this as sugar molecules that grab on to the nerves in the feet and decrease their function: known as glycosylation within the medical community. There’s good news and bad news in relation to glycosylation. The good news: in the beginning stages glycosylation is reversible – yay! The bad news: glycosylation can lead to detrimental insults to the plantar aspects of your feet and eventually your legs, working its way towards the center of the body.

The first step in understanding Diabetic Neuroapathy or glycosylation of the nerves begins with understanding the symptoms. Do you ever experience numbness or tingling in your feet? Think of it as the “pins and needles” you would feel if your foot fell asleep. Do you ever experience a “burning” type pain similar to when you hit your “funny bone?” These are both early signs of nerve changes in the feet and if not detected early on, their ability to be reversed is lost.

These feelings are a sign that the glucose levels in your blood stream are too high, and better diabetic blood sugar control is necessary on your part. Whether that means changing your diet, increasing your medications etc, to lower your blood glucose level, you need to take action. Taking such measures will help to decrease the effects of glycosylation and some sensation may return. However, once the glycosylation is too far along, these simple measures will no longer be helpful! Thus early detection is important, but prevention is key! Managing your blood glucose levels from day #1 of being diagnosed with diabetes will prevent and slow progression and development of sensation complications.

The effects that loss of sensation has on your feet are great! Once you have lost the ability to feel, you’ve also lost the ability to know that you’ve stepped on something and that you now have a wound or ulceration on the plantar aspect of your foot. When you don’t realize this, you don’t realize that treatment may be necessary, the area gets dirty, gets infected and leads to, in the worst-case scenario, infected bone and loss of toes.

If you’ve reached the point where Diabetic Neuropathy has affected you, there are still things that you can do to prevent ulceration and infection. It’s as simple as checking your feet daily. So, what should you look for? You should look for any changes since yesterday on the bottoms of your feet, around your ankles and in between your toes. By checking daily, you’ll notice any small differences immediately, even if you can’t feel them, and get treatment at the get-go. In addition, there are medications available that your Podiatric Physician can prescribe to help control the symptoms (burning, numbness, tingling) but none of these medications will restore feeling.

Don’t wait until the early signs of Diabetic Neuropathy set-in; control your blood sugar levels today and help prevent this complication for tomorrow!

You’re Not Always What You Eat When it Comes to Gout

Although drinking alcohol or eating “trigger” foods such as seafood sometimes induces gouty attacks, it’s not always the case! Gout can be triggered by various other factors including injury, infection, and crash diets – an attack may not always depend on what you’ve eaten, however it is always related to the levels of uric acid in the blood.

Gout is a form of arthritis that can be extremely painful in its most acute state when patients are suffering from a flare. It falls into the category of arthridities because when uric acid levels are high gouty crystals settle in joint spaces, typically the big toes or the elbows, and induce boney changes, ultimately affecting the function of the joint. There may be a genetic link, but post-menopausal women and men between the ages of 40 and 50 are more likely to suffer from gout. Children are rarely affected.

High uric acid levels do not cause symptoms in every individual; some patients are able to handle high levels and never develop symptoms, nor do they develop flares. However, in patients with a predisposition, for whatever reason, high levels of uric acid (greater thank 6.0 mg/dL) induce pain, inflammation, warmth and redness around the affected joint(s). The pain comes on suddenly and can be so severe that even bed sheets cause a discomfort! Often times, crepitus (the sound of rice crispies) can be heard and felt when the joint is mobilized. Crepitus is the movement of the uric acid crystals within and around the joint!

At the first sign of a gouty attack in the lower extremity, you should seek treatment from your Podiatrist rather than suffer through the pain. To help confirm your diagnosis they may want to send you for blood work to measure the uric acid levels in your blood in addition to taking a sample of fluid from the affected joint. Your Podiatrist may also take x-rays of the affected toe joints, as uric acid deposits can be seen on plain x-rays.

In addition to using such diagnostic tools, gout provides a very distinct clinical presentation and it is very likely that your Podiatrist will immediately try to treat your flare and decrease your discomfort. There are a variety of options that can help decrease an acute attack including a steroid injection into the joint and/or an oral anti-inflammatory medication, such as Indomethacin, to decrease inflammation and subsequent pain. Immediate treatment, in addition to decreasing symptoms, can also help decrease the long-term affects on the involved joint(s). Once the initial attack has been treated and uric acid levels return to normal, preventative medications are not necessary for one-time sufferers.

However, patients who have suffered from multiple gouty attacks and are predisposed to flares may be given a medication to take daily. Your Podiatrist will determine the best medication for your long-term control based on whether you are an “over-producer” of uric acid or an “under-excreter” of uric acid. The idea behind a daily medication is to maintain “normal” levels of uric acid in the body, thus lowering your risk of subsequent gouty attacks. It’s important to keep in mind that even at times when you’re not experiencing a flare, uric acid levels may still be elevated in the body, and joint damage can still take place!

As mentioned, the food you eat may not contribute to a gouty attack, but it can! Gout used to be known as the “Disease of Kings” because of its association with rich foods that Kings typically had access too. Foods that are high in purine (the chemical responsible for producing uric acid in the body), such as red meat, seafood, spinach, alcohol, mushrooms, and oatmeal, to name a few, should be kept to a minimum in patients predisposed to gout or gouty attacks. Gout has also been linked to medical conditions such as hypertension (high blood pressure), diabetes, hyperlipidemia (high cholesterol) and atherosclerosis (narrowing of the blood vessels), so it is important to manage your co-morbidities with your primary care physician in addition to keeping a good watch on your diet to limit your flares!

How Many Legs Does a Spider Have?

The answer to question “how many legs does a spider have?” is eight! However, the answer really doesn’t matter, as the most important question should really be: which leg did the spider bite? Spider bites, although not extremely common in the United States, do happen, and if you know the signs and symptoms, you will be one step ahead in the treatment process.

There are two spiders in the United States that one should be worried about: the Black Widow spider and the Brown Recluse spider. The more “deadly” of the two is the Black Widow spider, which can be identified by its black color and distinct red hourglass-shaped marking it bares on its underside. Unless you notice this spider on your skin, you may not know that you’ve been bitten, as the bite only feels like a pinprick. However, within the next several hours, you will realize that you’ve been bitten by something, as the area will swell and be accompanied by intense pain and redness. If you seek treatment, as most patients do once they notice symptoms, the bite of the Black Widow is rarely lethal.

The Brown Recluse spider also has a distinctive marking on its back that identifies it: a violin shaped marking. This spider is generally less lethal than the Black Widow, but does have severe side effects. The bite initially stings and one may notice mild redness at the site with increasing pain as time passes. Eventually, within eight hours, a fluid-filled blister will develop on the skin and remain for several days. The blister will subside, draining itself of its fluid, revealing a large burrowing ulceration that goes straight through the layers of your skin, down to bone. Aside from the burrowing ulcer the systemic symptoms (symptoms felt in various organs systems) include fever, rash, nausea, vomiting and intense fatigue.

As mentioned, knowing that you’ve been bitten by a spider, and even better, identifying the type of spider that it was, puts you ahead in the treatment process. As soon as you notice the bite, wash the area with soap and cool water. This will wash away any toxin that may be left behind on the skin from the time during which the spider was on your body. Cold compresses should also be applied, as they will help to decrease the inflammation and redness around the area. Of course, Tylenol or anti-histamines (such as Benadryl) can be taken to decrease pain and skin reaction or rash, however, keep track of what you’ve taken, so that if you seek medical attention, you can relay that information to the physician. If you experience swelling or vomiting with an associated fever, seek medical attention immediately. It may be that you require “anti-venom;” a medication that will counteract the bite of the Black Widow spider. If you’ve been bitten by a Brown Recluse spider, local medications, applied to the affected area, are usually sufficient for treatment.

As Podiatrists, Brown Recluse bites are the spider bites that we see most commonly. The reason being, that the side effect of their bite, is the burrowing ulcer. If on the foot or leg, a Podiatrist is fully qualified to treat the area with local wound care, applying wound products and dressings that will encourage the defect to fill in and eventually return your skin to normal over the course of several weeks. As a specialty, we are trained and qualified in wound care, so next time you suspect a spider bite that needs treatment, (although we don’t wish that upon you) seek out your local Podiatrist!

Brachy-Who?

Brachymetatarsia is a relatively uncommon disorder of the foot, but one that is interesting in its discussion. “Brachy” means short and “metatarsia” refers to the metatarsal bones (the long bones in the middle of the foot). A short metatarsal is one that is 5mm or more shorter than the length that it “should” be when compared to the adjacent metatarsals.

Patients develop this disorder due to premature closure of the growth plate in the affected metatarsal while the surrounding metatarsals continue to grow at a normal rate. The premature growth arrest can be congenital (something that we’re born with) or acquired throughout childhood. Congenital disorders that tend to lend themselves to brachymetatarsia include Down’s Syndrome, Turner’s Syndrome or bone enlargement. The most commonly acquired causes of ‘brachymet’ include trauma to the growth plate or infection both of which also arrest growth in the bone.

Most commonly, the 4th metatarsal is affected, and patients usually know something isn’t right, not by the symptoms they experience, but simply by the appearance of their foot. Their primary complaint upon presentation to a Podiatrist is that their toe “looks funny!” They may relay symptoms of calluses with associated pain beneath the adjacent metatarsals, a dorsal corn on the affected toe that rubs with shoe-wear, or contractures of both the affected digit and the surrounding digits. However, the conversation always leads back to the look of the toe. That is, their primary concern is cosmesis!

After x-ray evaluation, your Podiatrist will determine how short the metatarsal is in relation to the adjacent metatarsals, and although the number in millimeters doesn’t mean much to you as the patient, it means a lot in terms of how your Podiatrist can correct for this abnormality, should you opt for surgical correction.

Conservative options for Brachymetatarsia only treat the associated symptoms and will not treat the look of the digit. Options for treating the associated symptoms include padding, orthotics and trimming of corns and calluses associated with the deformity. However, since the primary patient complaint is the appearance of the digit, it is common that the patient selects surgical intervention.

In terms of surgical intervention, there are two choices: one-stage lengthening of the metatarsal vs. gradual lengthening of the metatarsal. One-stage lengthening involves a surgical break of the bone with insertion of bone bank bone into the defect. This will achieve lengthening of the metatarsal in one stage, but does have complications that involve compromise of the nerves and blood vessels surrounding the digit. Gradual lengthening of the metatarsal also involves a surgical break of the metatarsal bone, but rather than filling the defect, a distraction device is applied to the foot. Over a period of several weeks the distraction device is turned so as to lengthen the area of defect, allowing the body to make its own bone. The healing process in gradual lengthening does take longer but limits the risk to the surrounding nerves and vessels.

Your Podiatrist will recommend the surgical procedure that will work best for your case, with regards to the amount of lengthening required and your postoperative weight-bearing limitations. Keep in mind, however, that with any surgical procedure, although you will lengthen the toe and improve the overall alignment of the foot, you will have a scar on the top of the foot. Careful consideration, before opting for surgical correction for your Brachymetatarsia, is necessary and it is a decision that should not be taken lightly.

Derma-What?!

Even though the temperatures can often be stifling, someone has to get out and clean up your yard and garden this summer, so it might be that you find yourself spending this Saturday afternoon outside fulfilling those “yardly duties” of yours! One of the most commonly seen problems in patients who spend weekends tending their property is Contact Dermatitis. “Derma” meaning skin and “itis” meaning inflammation takes the guess work out of deciphering the meaning of Dermatitis. Thus, Contact Dermatitis is inflammation of the skin caused by the skin coming in contact with some object. Usually the skin reaction takes the form of a rash, sometimes in exactly the shape of the offending agent and other times spreading up the legs or arms leaving the patient questioning what it was that reacted with their skin. It can be itchy, painful or even burn and sometimes patients have symptoms of all three! It makes for a very uncomfortable few weeks as the rash clears, thus prevention in key.

Most people know what poison ivy is and that it causes a significant itchy rash in some patients when encountered. Other patients, not so much! Poison ivy is a form of Contact Dermatitis knows as “Allergic Contact Dermatitis.” When it comes in contact with the skin, in some patients it initiates a response by the body much the same as would occur in an allergic reaction to something that you’ve eaten. The only difference in this case, is that the trigger for the response was external (poison ivy plant) rather than internal (peanuts for example). The bodies immune system over-reacts to the poison ivy that has contacted the skin and cells are released that form the itchy rash we often associate with this plant. Other materials that commonly cause an Allergic Contact Dermatitis include nickel (found in jewelry), latex, hair dyes and shampoos or skin lotions containing fragrances.

In contrast to Allergic Contact Dermatitis, Irritant Contact Dermatitis does not initiate a response from the immune system. This reaction is simply a skin reaction that progresses the longer the skin is in contact with the offending agent. The most common cause includes household detergents and the reaction usually takes on the feeling of burning on the skin, rather than an itchy rash.

Deciphering between allergic and irritant forms of dermatitis can be difficult, but the good news is that both forms are usually treated in much the same way. Be sure that if you know you’ve come in contact with a material that reacts with your skin, you wash the areas immediately with cool water and soap, being careful not to increase the size of the area contacted. Cold compresses can help in situations where blistering has developed and the use of calamine lotion or over the counter anti-histamines (benadryl) can help relieve itching. Over the counter hydrocortisone creams can also help calm the skin reaction and alleviate symptoms quicker than without such creams, although the rash will resolve on its own over several weeks. If over the counter agents don’t seem to be doing the trick, seek out your physician, who can prescribe topicals that are slightly stronger, but accomplish the same tasks. Rashes on the legs and feet are well within the scope of your Podiatrist, so head to their office if symptoms persist!

Prevention is simple: don’t garden or tend to the yard! Although that might sound nice, unfortunately, avoiding the yard may not be an option, but there are some other steps you can take to protect yourself and your skin. Wearing pants, or long-sleeved shirts with gloves on your hands is the best option for protecting your extremities, in addition to wearing closed-toed sneakers or gardening shoes, however, all that clothing can be constricting and hot! Therefore, if you’re able to get up a little early this weekend, get out to the yard first thing before the temperatures have climbed up into the 90’s. You’ll be finished your work long before the temperatures rise, leaving the rest of the afternoon for lounging by the pool. In addition, if you’re one of the lucky ones and you know which plants or weeds in your yard induce a reaction in you avoid them and wait for another family member to come along and help you!

Sweaty, Sweaty, Smelly Feet!

Some people sweat, and other’s sweat a lot! What makes the difference between these two patient populations is a condition known as hyperhidrosis. Hyperhidrosis literally means “a lot of water.” It is a condition that refers to an increased amount of perspiration (sweating) in a number of locations on a patient’s body including their face, hands, armpits and feet.

The greatest complaint for people with hyperhidrosis of the soles of their feet is the odor left behind. With sweating, moisture accumulates in socks and on shoes of such individuals and eventually odor-causing bacteria build-up resulting in an increase in odor, with subsequent embarrassment.

Although hyperhidrosis may be attributed to neurologic complications or sympathetic overactivity, a large percentage of patients with this condition have no contributing factors and suffer from this “just because.” In patients that have no predisposing conditions prevention is not the goal of treatment, but rather control of their excessive perspiration.

Hyperhidrosis can be very difficult to treat, and patience is a virtue while working with your Podiatrist to find a solution that works best for you! For starters, its best to keep feet clean and to change socks daily to prevent bacteria from colonizing on your feet, your socks or your shoes. Do not spray perfumes or body sprays on the feet in attempt to decrease odor as this can often increase the odor due to chemical reactions between sweat and perfume.

Antiperspirants are the first line in treating hyperhidrosis, as many patients immediately notice a difference and thus, success is achieved! Antiperspirants for the feet come in the form of deodorant sticks that one would use for the underarm; in fact there are some over the counter antiperspirant sticks that are indicated for use on the soles of the feet. Look for products that contain aluminum chloride hexahydrate, as they are most effective in treatment. Your Podiatrist may write you a prescription for such antiperspirants containing as much as 30% hexahydrate for prevention of sweating. Through prevention of sweating, antiperspirants are often successful in decreasing bacterial build-up and eliminating odor of the feet. These products are best applied to the feet twice daily: once in the morning and once in the evening, and are applied to the soles of the feet just as deodorant would be applied to the underarms.

For patients who suffer from hyperhidrosis due to sympathetic overactivity or neurologic complications, prescription medications that act on the peripheral nervous system can be tried. However, it is uncommon that your Podiatrist will recommend or even prescribe such mediations due to the potential side effects these can induce on the body.

Iontophoresis is a completely non-invasive method for attempting to treat hyperhidrosis of the hands and feet that utilizes water to pass a mild electronic current through the patients skin. Although not completely understood, the belief behind this theory is based on a cooperative effect of the electrical current and the water to increase the thickness of the outside layer of the hands and feet. Thus, the ducts for which sweat is released from the body onto the palms and soles become essentially “blocked.” Several treatments, on consecutive days helps patients reach a significant decrease in their perspiration, with subsequent maintenance treatments as needed, usually once every 2-4 weeks.

Finally, a treatment method that has gained popularity over the last 5 years or so is Botox injections. Botulinum Toxin, or Botox (the same material used on the face for decreasing wrinkles) can be injected into the soles of the feet for relief of hyperhidrosis. The toxin works by blocking a hormone in the body that is normally responsible for turning sweat glands “on.” This toxin, by blocking that hormone, turns sweat glands “off” and leads to a reduction in sweating in the areas where it was injected. Your Podiatrist will determine how many injections you will need and based on your clinical presentation, how often follow-up injection should be given. These injections are certainly not a cure for hyperhidrosis, but they control symptoms for a significant length of time; in some patients up to 7 months.

Hyperhidrosis is a difficult condition to treat, but your Podiatrist can guide you through your treatment options and find a combination that works best for you. Having feet that smell like roses is just within your reach!

Still Walking Barefoot? Here’s One More Reason Not To!

Following in the path of last’s weeks Blog, where we discussed foreign object injuries to the foot, this week I would like to talk about broken toes! As with stepping on a foreign object, broken toes are more often than not suffered when there is a lack of shoe involvement: meaning when patients are barefoot. Of course, a broken toe injury can come at anytime, even with shoes, but that doesn’t seem to be the common occurrence.

Depending on which toe, the severity of the break, and exactly where the toe has been broken, can alter the course of treatment, so its important that we first talk about which bones are where in the anatomy of your foot.

A normal foot has 4 toes (2, 3, 4 & 5) and 1 hallux (“big toe”). Toes 2-5 have 3 small bones and one larger, longer bone. The small bones are called “phalanges,” and are named according to their location: distal (furthest from the body), middle and proximal (closest to the body). The larger bone is called a metatarsal and is named by the number toe that it corresponds to. To simplify, the third toe of the foot consists of the distal, middle and proximal phalanges and the third metatarsal bone. The hallux, or “big toe” contains only 2 small bones: the proximal and distal phalanx; and a larger 1st metatarsal bone.

Each bone communicates with the next across a joint, which is surrounded by a capsule and allows for motion to occur between those two bones: bending and extending of the toes. The joint of most importance, when dealing with toes is what’s called the “metatarsal-phalangeal joint” (MPJ). This is the joint between the larger metatarsal bone and the proximal phalanx. As we will discuss in a minute, determination of conservative and surgical treatment for a broken toe depends partly on the joint involved.

The typical “toe fracture” occurs when the toe is “stubbed” or “jammed” into the floor or into an object such as a step, or when an object is dropped onto the toe. The patient usually admits that injury has taken place while they were wearing no shoes, or slippers, neither of which provides any protection to the toes! Whether the toe was stubbed or an object was dropped on to it, pain will be immediate and swelling of the toe or toes will follow suit! You may immediately, or shortly notice bruising of the toe and/or changes in the look of the nail, if it has been injured. Rarely, the bone that has been fractured will be sticking out through the skin; an open fracture. Certainly, if bone is sticking out of the skin, a trip to the Emergency Room is a necessity.

Following injury, it is important to keep a close watch on the area involved for new pains, increased pain, or a worsening in appearance. Loss of sensation, numbness, tingling or an unusually cold toe should all throw up red flags and encourage you to seek medical attention immediately. In the mean time rest, ice, elevation and over-the-counter anti-inflammatory medications can be used to decrease swelling and pain to the injured area.

Differentiating between a fractured toe and one that is badly bruised is often difficult, unless the toe appears grossly deformed. Being that this is the case, if medical treatment is sought, an x-ray of the involved foot is likely. The x-ray will provide the Podiatrist will a lot of information to help guide your treatment: location of the fracture (if there is one), if the bones are displaced or if they are in good alignment, if a joint is involved in the fracture, how many pieces the bone is in, and whether or not conservative or surgical treatment is necessary.

If the fracture is located in one of the phalanges, is in good alignment and does not involve a joint, conservative treatment with the use of “buddy taping” and a surgical shoe to protect the toe while it heals will be initiated. If the bone appears as though it is displaced, involves the joint and is in several pieces, surgical treatment becomes a greater possibility. Surgery attempts to realign the pieces of the bone and hold them in position while they heal themselves.

As was mentioned before, involvement of the MPJ presents a bit more serious of a problem than if one of the smaller joints in the toe was disrupted. The MPJ plays a significant role in walking and provides a lot of structural support to the foot. Therefore, involvement of the MPJ will require surgery with “pin” fixation and non-weight bearing post-operatively to allow for appropriate healing to take place.

The moral of the story this week, as it was last week, is: don’t walk around without shoes on! Leaving the foot unprotected, whether it is the toes or the sole of the foot, greatly increases your risk of injury. Next time you get up off the beach blanket and head back to your summer beach house for lunch, make sure to put your shoes on and protect your feet.

Think Twice Before Kicking Off Those Summer Shoes

The top four reasons not to walk around without shoes are as follows: sewing needles, glass, wood (toothpicks) and metal.

Year after year, once the Memorial Holiday has been celebrated, shoes are often left behind in the house, around the pool, or on the beach blanket! During the summer months, patients complain that shoes can be “constricting,” “hot,” and “uncomfortable,” but I can assure you that nothing will be more uncomfortable than a foreign object that’s found its way into the sole of your foot.

If you step on an object, the initial response is to immediately extract it from your foot, but this may not always be the best course of action. Unlike splinters on the hand, when you step on an object the potential for it to penetrate far into the sole of the foot is great, for the simple fact that you’ve stepped on it! Refrain from extracting the object yourself, especially if there is immediate and profound bleeding or if you have an immediate loss of sensation to the foot/toes or burning and tingling sensations. These may be signs that important structures within the foot have been penetrated and without visualization of those structures, more damage can be induced upon retrieval of the object! Getting yourself to the Emergency Room is your best course of action with this type of injury.

In such a situation it is important that you know a few things about your health to help guide appropriate treatment once you’ve reached the hospital. It is important to know if you have been immunized against Tetanus bacteria and how current your immunization is. If your immunization or “booster” shot was within the last 5 years, it is unlikely that you will need to receive a “booster” in the emergency department, however, if your last “booster” shot was greater than five years ago, you will need to a “booster” shot to ensure coverage against Tetanus bacterium. If you have never been immunized, you will be given a series of two injections: one for immediate immunization against tetanus bacteria and a subsequent injection for long-term immunization.

Knowing which medications you are allergic to and what your body’s response to taking those medications is will help the ER Physician in prescribing an antibiotic. Whether the foreign object stays lodged in the sole of the foot or not, it carries the potential to generate infection and initiate an immune response by the body. The reason it carries this potential is because most objects encountered while walking barefoot are not sterile and thus bacteria is inherent to them. Once the skin barrier is broken and the object enters the sole of the foot, infection becomes a possibility and the body identifies that object as foreign and works to “fight against” it.

After initial treatment has been started, the Podiatric Physician “On-Call” will come and evaluate your injuries in the emergency department. Depending on the type of object that is lodged in the foot and whether there is immediate danger to your foot or not, will determine the Podiatrist’s next course of action. They may first ask for x-rays, an MRI, CT scan or Ultrasound of the foot in order to locate the object, determine what, if any structures the object is penetrating and to better determine the next course of action in treating your injury. If there is imminent danger to your foot, meaning there are concerns about viability of the tissue, nerve penetration and compromised blood supply, the Podiatrist may want to take you to the operating room immediately to extract the object, clean out the tissues, and repair any damage.

No matter what the immediate course of action, once the object has been removed you will be given a 10-day course of antibiotics for prevention of infection. You will also need to follow up with the Podiatric Physician who treated you in the hospital, for evaluation of the site of penetration and to monitor healing.

The next time you think about walking around the house or the backyard without shoes, think again! Going barefoot is certainly not worth the risk of stepping on an object, lodging it into your foot and increasing your chance of infection with a subsequent recovery period during the beautiful summer vacation months!

For the diabetic population, especially those patients with neuropathy, walking without shoes is never a good idea. You are less likely to feel an object penetrate your foot, thus you are less likely to seek treatment and more likely to contract infection with poor healing outcomes due to the nature of diabetes.

Shin-splints May Not Be What You Think They Are!

Shin-splints, especially to a high school track athlete, can be very debilitating and recovery periods can exclude competitive participation for several weeks as the healing process takes place. The definition of a shin-splint is variable, depending on who you ask, so it is first important to begin by differentiating between what the average citizen calls a shin-splint and what a “true” shin-splint really is.

Most people diagnose themselves with shin-splints when they have pain anywhere in the front of their leg. However, true shin-splints delineate pain within the bone in the front, or anterior portion of the leg (tibia), as inflammation of the periosteum of the bone itself is what induces shin-splint pain. Every bone in the body is covered by periosteum, which is the outer covering of bone providing the bone with its blood supply and allowing it to thrive. When the periosteum is disrupted as is the case in shin-splints, the periosteum reacts generating inflammation, pain and swelling. In shin-splints, he periosteum becomes disrupted when the muscles attaching to it, and to the bone that it surrounds, apply “pull” on the bone, creating a periosteal reaction. The resultant symptoms include pain that is increased with activity, especially early in a workout session, as well as pain with pointing the toes downward (plantar flexion) of the foot.

The question becomes: why are muscles in the leg applying extra pull to the periosteum and bone, so much so that they generate a periosteal reaction? The answer: it can be a number of things!

Running on uneven surfaces is a huge contributor to the development of shin-splints. This often occurs during pre-season training sessions and in cross-country runners, who are constantly running from pavement to grass, and gravel to synthetic track surfaces. The extra stress and strain on the muscles of the leg as they adjust from one surface to the next creates disruption of the periosteum and eventually, symptomatic shin-splints. In addition to uneven surfaces, improper training techniques can also be an inducer of leg pain and increased pull of the muscles on the tibial bone, leading to shin-splints. As a young athlete it is important to have a regimented training routine that has been reviewed by a coach or trainer who can advise you on what workouts are best for your specialty, but also best for your body and your health!

There are also outside factors, unrelated to athletic activity, that can contribute to the development of shin-splints, which include flat feet (pes plano valgus) and calf tightness. We’ve touched on calf tightness before and its contribution to heel pain syndrome (plantar fasciitis), and unfortunately, the same etiology applies here! When the calf muscles are tight, they don’t allow the ankle joint to work maximally, flexing the foot upwards and downwards as intended. Therefore, in order to get the motion at the ankle joint that is needed for daily activity, the body looks elsewhere and tends to apply stress on the muscles of the anterior and posterior leg. Prevention and treatment of shin-splints in patients who have calf tightness as the sole etiology of their problem can be quickly rectified with some simple stretching exercises!

Take a look back at our blog entitled “Plantar Fasciitis,” posted on May 5, 2010 (http://advancedfootcarecenters.com/blog/?p=143). The following stretches mentioned in that blog can also apply here and should be used daily whether you suffer from symptoms of shin splints or not, as they can be great preventative exercises:
A. Wall Gastrocnemius Stretch
B. Stair Gasctrocnemius Stretch
C. Soleus Stretch

Shin-splints can be extremely painful and can result in a withdrawl from activity for several weeks as the body heals itself and the periosteal reaction subsides. Rest is certainly the best thing, but application of ice is also helpful to decrease inflammation. Anti-inflammatory medications can also be beneficial in decreasing symptomatic pain in addition to helping control inflammation of the periosteum, leading to a faster recovery! In prevention, stretching as mentioned above is extremely important in addition to wearing appropriate shoes and running on even and shock absorbing surfaces such as synthetic tracks, as opposed to sidewalks and grass. Shin-splints can be very debilitating to the competitive athlete, thus it is important to treat them at their onset, otherwise your recovery period increases as the pain and inflammation takes longer to leave the bone.