You want to use what to heal my Ulcer?

Chronic ulceration has been an ever increasing problem with the rise of diabetes.  As time has gone on, new techniques have been developed in an effort to help ulcers heal faster and more definitively.  Some techniques have lost favor in practice, while others have become standard of care.  One technique has changed how we treat ulcers, and it may surprise you where this product comes from.  Let’s define a few terms first.

An autograft is taking tissue from one part of the body and using it somewhere else on the same person.  An example of an autograft would be taking a vein from your leg to use in the heart in bypass surgery, or taking skin from the buttock to cover a burn or ulcer.  An allograft is taking living tissue from one human being and using it in on another human being.  This is the principle currently being used to help heal chronic non-healing ulcers.

Dermagraft and Apligraft are examples of autografts that have been developed to help close diabetic ulcers.  These two products are derived from neonatal foreskin.  Yep, that’s right…  we’ve taken the skin after circumcision and put it together with growth factors to make it grow.  The skin is then cut into smaller squares, packaged, and sent refrigerated so that it can be used in offices across the country.  These grafts contain living cells on a “scaffold” that can integrate with the patient’s skin.  Studies of these products have shown that increase the likelihood of an ulcer healing.

These products are not cheap, but because of their incredible performance in helping diabetic patients, many insurances including Medicare cover anywhere up to six applications of this products.  Your podiatrist can help you understand more about these treatments.

I thought My Ulcer was Healed

So you had an ulcer that you thought had closed up, but every time you visit the podiatrist, he takes a scalpel to your foot and opens the ulcer back up. Why does he do that? Before I answer, let’s talk about three things that an ulcer needs to heal: Offloading, Blood Flow, and Decreased Bacterial Load.

Offloading means taking precautions to insure no weight is being put on the ulcer. This means altering shoe wear or even totally immobilizing the foot with the ulcer. If safety measures are not taken to avoid walking on the ulcer, the friction and sheer forces will not allow a diabetic’s delicate skin to heal over the ulcer.

Blood flow is the key to all healing. It contains the growth factors and oxygen needed for the skin to grow over and close the ulcer. In an effort to close the wound, the body will lay down fibrotic tissue. The wound then becomes “senescent” or asleep, meaning the body forgets that it’s there and stops sending blood and healing factors to it.

Bacteria is naturally found on our bodies, but it can’t penetrate intact skin. Once an ulcer opens up, bacteria can enter and produce substances that stop healing. Bacteria can even enter the blood stream and cause additional problems elsewhere.

Now, you were wondering why the podiatrist cuts you up when you come in. By removing the yellow, fibrotic tissue, we “wake up” the body, reminding it that a wound is there so it continues to send healing factors. We like to cut so that we see bleeding, pink tissue so that we know blood is reaching the wound. Bacteria like to grow on the fibrotic tissue, so by removing it, we decrease the bacteria load on the wound. And lastly, you are less likely to walk on a bleeding wound compared to a wound that looks healed over. By following these guidelines, the healing time of an ulcer is much faster.

What can I do about my Neuropathy?

We have discussed in this blog the many issues a diabetic may face in maintaining their health.  Neuropathy, or loss of sensation, is a major contributor to the development of pain and diabetic ulcers.  What can be done to battle this problem? Let’s discuss.

First and foremost, a person with diabetes must look at their feet frequently.  Their eyes need to become surrogate nerves for their feet.  By performing a daily inspection of the soles of their feet, in between the toes, and on top, they are more apt to finding a developing ulcer sooner.  If it is too difficult to inspect their feet themselves, have a family member do it, or place a mirror somewhere it can be used to see the feet.

Another important tool that can be used is a temperature gauge like the TempTouch.  An ulcer usually occurs because of excess pressure and friction on a certain spot on the foot.  These rubbing forces create heat.  By using a device that can measure the temperature of the skin, you can get an idea of where the pressure and friction are concentrated before an ulcer occurs i.e. the hot spots.  You can then take measures to off-load or add extra padding to that part of the foot.  This type of temperature gauge can help alert you before an ulcer occurs, and it costs about the same as a month’s worth of neuropathy medication.

Lastly, there have been some recent advances in pharmaceutical treatment of neuropathy.  Lyrica and Cymbalta are two newer drugs that have been very effective.  In the past, neuropathy medications required you to take them three times a day and you needed to slowly build up the levels in your body to avoid side effects.  Both Cymbalta and Lyrica are taken once a day, do not require slow introduction, have very minimal side effects, and provide relief sooner.

The Issues Diabetics Face

November is Diabetes Awareness month, and in that spirit, I wanted to discuss some of the reasons why diabetics face the challenges that they do.  The three subjects that diabetics commonly wrestle with are neuropathy, immunopathy, and vasculopathy.  All three are tied to the excess blood sugar present in a diabetic patient.

Neuropathy is a term meaning malfunctioning nerves.  As mentioned before, a diabetic patients blood sugar is not as tightly controlled as a non-diabetic.   Often the excess sugar will begin to deposit in places it is not normally found, like a nerve.  Sugar is osmotically active, meaning that sugar will attract water to it.   When sugar draws excess water to a nerve, the nerve begins to swell and be compressed against surrounding tissue.  This can cause numbness, or a low aching pain, especially in the legs and feet.  When nerves stop functioning, a person loses the ability to sense pain.  This lack of sensation may be so blatant that a diabetic could step on a nail and not feel a thing.

Immunopathy is a term meaning a malfunctioning immune system.  White blood cells are the cells that protect the body from bacteria and other infections.  They help the heal cuts and scrapes we get normally.  But just like before, high blood sugar causes white blood cells to malfunction.  Instead of wounds healing fast and clean, non-healing ulcers can form.  These ulcers can act as entry points for bacteria into the body.

Vasculopathy is a term meaning malfunctioning arteries and veins.  It has been shown that diabetic arteries tend to harden and become narrowed very fast.  So  in addition to not feeling pain when an injury happens and white blood cells not healing the injury, diabetics have decreased blood flow to the legs and feet, thus decreasing the chance of healing an injury.

If not cared for quickly, a non-healing wound on the legs or feet may set the stage for amputation.   It is imperative for diabetic patients to routinely see a podiatrist.   Their feet will thank them.

Charcot Marie Tooth Disease

We’ll return to the skin discussion soon, but I’ve seen two cases of a relatively rare neurological disease walk in the door in the last week, so I thought it would be worth it to talk about it.

Charcot Marie Tooth is a disease that affects the myelin sheaths that cover the nerves in the body.  If we think of a nerve as being an electric wire transmitting signals, myelin is like the insulation around the wire to make the signal travel faster to its destination.  It is precisely a defect in the myelin that causes the signals that the brain sends out to be slower and inconsistent.

The nerves that have to travel the farthest are usually the first to be effected in Charcot Marie Tooth.  Therefore, the small muscles in the feet and legs tend to show the first signs of the disease.  Because these muscles are not being stimulated in a normal fashion, they begin to get smaller and tighten up.  The calf muscles get so small that patient’s legs have been compared to “stork legs” or “upside down champagne bottles.”  The tightening causes the toes to permanently curl up, the arch to be extremely high, and the Achilles tendon to be so tight that you can only walk on the ball of the foot.  As you can imagine, this makes it very difficult to keep your balance when walking.

The disease is progressive, meaning that it starts without any obvious warning, and it worsens year after year.  Due to its slow onset and progressive nature, someone can go years without being diagnosed.  It will become more and more difficult to walk and the pressure on the forefoot can be so dramatic that deep calluses and even ulcerations can form on the ball of the foot.  As the disease progresses, the hand muscles can become involved.

If there is a bright side to this condition, it is that it does not affect a person’s ability to think or their memory.  Their lifespan is expected to be normal.  However, if gone untreated for decades, it may confine a person to a wheelchair.  We’ll discuss next week how to detect the early signs of the disease, the diagnostic tests that can help, and the treatments available.

Stasis Dermatitis Treatments

Now that we understand how to recognize stasis dermatitis, let’s discuss what can be done to treat the problem.

Unfortunately, it is impossible to repair the old valves in our veins. However, we can try to compensate for their malfunction by trying to make their job easier. This is done by elevating the legs above the heart when sleeping or lying down. This allows gravity to move the fluid back to the heart. There are even leg pumps that you can use to mechanically massage the leg and move the fluid back into circulation.

Obviously, it is not always possible to keep the legs above the heart. For these instances, a person can wear compressive stockings that help to put pressure on the lower leg and foot so as to minimize the space fluid can collect. These can be worn all day long, or even during air travel to keep blood from pooling in the legs and feet.

One word of caution… Patients who have heart conditions may need to check with their cardiologist before they engage in increasing the fluid flow back to the heart. If the heart cannot handle the extra fluid, they may put themselves into heart failure. It is better to have some swollen ankles than overloading the heart with an amount work that it cannot handle.

As mentioned before, stasis dermatitis can also cause the legs to become very itchy and uncomfortable. Topical corticosteroid cream can be used to combat this discomfort. But again, be judicious with this cream as it may cause the skin to become very thin and fragile.

If treated correctly, venous ulcers can be avoided. Work with your podiatrist in management of your condition to get the best outcome.

Smoking and Healing

It is important to understand the adverse effects of smoking tobacco in regards to the recovery and outcome of a surgical procedure. Smoking tobacco introduces three main substances that may lead to a longer recovery or undesired outcome.

1. Nicotene – Nicotene constricts blood vessels, leading to decreased blood flow
2. Carbon Monoxide – Carbon Monoxide decreases the amount of oxygen your blood can carry
3. Hydrogen Cyanide – Cyanide decreases your cell’s ability to make energy to repair itself.

When combined together, these substances substantially slow the healing process and allow complications to occur. Patients who continue to smoke prior to and after surgery have increased risk of their surgical wound opening back up, leading to infection and slowed healing of the bone and skin.

Although complete cessation of smoking would be the ideal approach, this often is not a realistic option.
However, if a patient managed to stop smoking a couple weeks before surgery, and maintained that during the recovery period, the healing of skin and bone would be dramatically increased. When it comes to bone and skin healing, ceasing to smoke can have immediate benefits. Although the long term effects of smoking remain, removal of nicotine and carbon monoxide will intensely improve the flow of oxygen to the tissues.

Even if a patient only was able to stop smoking for a few days before and after, studies show patients are more likely to heal faster without complication than patients who continued to smoke.

In you are currently preparing to undergo a foot or ankle surgical procedure, please carefully consider the benefits of avoiding smoking leading up to your surgery date. If you have any concerns or questions, feel free to discuss them with your podiatrist during your next office visit.

Keep the Blood Pumping

Let’s revisit our discussion on dermatitis. So far, the forms of dermatitis that we have discussed had to do with a substance irritating the surface of the skin. But it is important to remember that there are internal factors that can cause dermatitis.

Stasis dermatitis is a form of skin irritation that results from problems with blood flow, especially on the lower leg. Under normal circumstances, blood flows away from the heart in arteries, unloads the oxygen it carries to body organs and tissues, then ending its journey by flowing back to the heart in veins. In order to prevent backflow of blood, veins have valves that make sure to keep blood flowing in the correct direction.

With stasis dermatitis, the valves in veins can malfunction and lose their ability to direct blood flow. Instead of being directed back to the heart, the blood pools and sits in the veins in the foot and lower leg. The veins begin to expand as the volume of blood within them increases. This leads to increased pressure inside the veins, pushing fluid out into the skin, giving the lower leg a swollen appearance. In addition, some of the pooling red blood cells can break down and cause the overlying skin to be discolored. The skin can become itchy, and it may cause people to have night cramping.

Probably the most serious complication of this condition is called a stasis ulcer. Unlike other ulcers, this sore is not due to friction or trauma. It is thought that the overlying skin is starved of adequate oxygen, causing the skin to die and form a very painful ulcer. To make matters worse, the ulcer usually does not heal quickly and can be an entry point for infectious bacteria into the body.

Luckily, podiatrists have become specialists in this arena of medicine. There are many potential treatments available that have shown to be beneficial. We’ll discuss treatment options in our next blog post.

There is a reason why they call it the Achilles

We’ve been talking about skin problems the last couple weeks, and we will return to that subject next week.  But this week something happened that has convinced me to discuss something else.

The Philadelphia Phillies are a baseball team that was expected to reach the World Series this year.  However, they were on the brink of being eliminated from the playoffs by the St. Louis Cardinals this last week.  Ryan Howard, the 1^st baseman for the Phillies was Philadelphia’s last hope.  Unfortunately, he made the last out to end the game.  To make matters worse, as Howard tried to run to first base, he fell to the ground in pain.  Once evaluated, it was apparent that he had ruptured his Achilles tendon.

Achilles tendon ruptures are common and often happen with abrupt pivoting movements or when someone starts exercising after a long period of inactivity.  When it happens, the person describes the event as if they were hit in the back of their heel with a bat and they hear an audible pop.  Incredibly, they will still be able to walk, but with dramatic difficulty.  If you run your finger up the back of the heel, you’ll feel a depression or soft spot instead of the normal tense tendon inserting into the heel.  Some ruptures are partial while others may be complete.  If the rupture is bad enough, the tendon can recoil on itself like a fruit rollup.

If you try to treat a rupture conservatively, the recovery time is longer and the risk for re-rupture is very high.  For that reason, ruptures are most effectively treated with surgical repair.  Although you take on the risks of surgery, surgical repairs allow for better results long term.  You often can resume exercise sooner, the motion in the ankle is better, and overall the patients have fewer complaints.  Your podiatrist is a skilled surgeon that can perform this surgery and help you along your road to recovery.

Psoriasis Made Simple

Another dermatological term loosely thrown around is psoriasis.  Let’s discuss in more detail what this term really means.

The cells in our skin are known as keratinocytes.  These cells evolve from the basement part of our skin, but then proceed to migrate to our outer layers and die.  This process allows for continuous renewal of our skin.  Once a cell is “born,” it takes about 28 days or 4 weeks for it reach our skin’s surface and fall off.

Now, imagine instead of a month, this process took place in just 24 hours.  Such is the case with psoriasis.  Too many keratinocytes are produced in a very short amount of time.  The outer cells are pushed out faster than they can fall off.  This causes the skin to become very thick and elevated, especially on the elbows, knees, top of the feet, back, and scalp.  The elevated plaques are salmon colored and become shiny, like the skin of a fish.    Depending on circumstances, these plaques will go into remission but reoccur many times through a person’s life.

What causes psoriasis you ask? Psoriasis is usually something that runs in the family, and the first outbreak may be preceded by strep throat or a viral infection, or some other stressful event.  However, the exact causes are until unclear.  In more severe cases, psoriasis can spread into the joints and cause psoriatic arthritis.
How can you know if you have psoriasis?  If you’ve ever cut yourself where the skin was previously normal, but afterward had an elevated plaque show up on that spot similar to the plaques you have on your elbows and tops of your feet, check with your doctor to rule out this condition.

Fortunately, psoriasis does not shorten a person’s lifespan or lead to skin cancer.  Nonetheless, it can become a cosmetic nuisance depending on its location.  Thankfully, there are many treatments available including UV light, topical corticosteroids, and special wound dressings that can keep outbreaks in check.  More aggressive treatments are available if necessary.  Your podiatrist can help manage psoriasis that presents on the feet and toes.

Eczema Revealed!

Eczema… It’s a word we have all heard before, and a word we’ve probably used when describing someone’s skin. But what does it really mean?

Eczema is an “umbrella” term or “catch-all” phrase. It encompasses a wide variety of skin conditions that really have little or no relation to each other. In truth, eczema is a non-specific word whose definition is not clearly defined. Even among medical professionals, there is confusion on the true definition of the word.
For that reason, instead of eczema, we will use the word dermatitis, meaning inflamed skin. There are many causes of dermatitis, and we will discuss a couple here.

Contact Dermatitis is a skin reaction to something that comes into contact with our skin. This category can be further broken down into two categories: Irritation Contact Dermatitis, and Allergic Contact Dermatitis.
Irritation Contact Dermatitis is a skin reaction to a substance that most everyone would react to if they were exposed. Examples include exposure to harmful chemicals, harsh cleaning products, highly concentrated detergents, and strong solvents. This also includes diaper rash in babies when their skin is exposed to urine or stool for a prolonged period. Non-prescription lotions and creams may help to decrease itchiness and soothe the rash. On the foot, this condition may present after buying new shoes which use cement or other manufacturing agent that irritates your skin.

Allergic Contact Dermatitis is a skin reaction that only occurs if you are particularly sensitive to a specific substance. This is the proverbial “allergic reaction” people can have to different plants, fragrances, nickel or other metals, latex, or medications. Even if you aren’t originally allergic to one of these agents, with repeated exposure, you can develop them.

How can you tell if it’s allergic or irritation dermatitis? If it is irritation, the rash shows up the first time you are exposed to the agent, and the rash comes immediately after exposure. If it is an allergy, you will not develop a rash the first or even second time you are exposed. It is only after you have been exposed a couple of times that you develop a rash, and after exposure, the rash does not show up for a day or two. Your podiatrist can help recognize these types of reactions on the feet and give appropriate treatment.

Your Epidermis is showing!

We probably all fell for that joke as kids, but all joking aside, some of the terms used in medicine can be tricky to understand. Medicine is a foreign language that must be learned as if you were learning Spanish or French. Dermatology seems to be a branch of medicine that has unfamiliar or confusing terminology. I would like to address different skin conditions that can manifest in the feet and how they vary. But before we discuss them, I think it would be beneficial to review the components of skin.

The outermost layer of the skin is called the epidermis (0.04 mm thick). There is no blood supply to it and there are no nerves within it. This layer protects your muscles and internal organs from the external environment, and can be considered part of the immune system. The epidermis can be broken down into 5 different layers. One of these layers is responsible for cell division, which replaces the dead skin that falls off.

A different layer contains melanocytes which are responsible for skin color. Another layer contains cells that are “sown” tightly together to prevent passage of foreign elements. Yet another layer secretes a fatty substance that acts a barrier to water and other harmful substances. This is a very robust barrier that is tough to cross, which is why you don’t do not swell up with water when you go swimming!

Maybe you have heard that anything you put on your skin (lotions, make-up, etc.) gets into your blood. But when we remember that there are no arteries in the epidermis, that a layer of cells are tightly packed together, and that a substance must pass the fatty barrier to reach our blood, you can be assured that almost nothing gets across. Only harsh chemicals in highly concentrated amounts should cause you to worry.

The middle layer of the skin is called the dermis (0.5 mm thick). This layer contains blood vessels, nerves, glands, and hair follicles. Collagen and elastin give structural strength to the dermis. Depending on the area of the body, the skin will have different glands that secrete either a smelly substance (armpits, groin), a watery substance (palms of hands, soles of feet), or an oily substance (causes acne).

The last layer of the skin is called the hypodermis or subcutaneous tissue. This layer is made up of fat cells and allows the skin to slide without friction over the underlying muscle and bone.
Each of these layers (or structures within a layer) can be struck with disease. We will discuss common foot dermatologic conditions in our next series of posts.

Give Me the Antibiotics and No One Gets Hurt

Historically, the first antibiotic discovered was penicillin. Although it was discovered several years before World War II, it was not widely manufactured and distributed until the war. This antibiotic has advanced into an entire family of antibiotic drugs to treat different types of bacteria. Previously untreatable staph and strep bacterial infections have become manageable conditions. The discovery and use of antibiotics has without a doubt saved millions of lives. Amoxicillin and Erythromycin are examples of antibiotics currently in use.

So, if antibiotics are so great, why is it that doctors often send people away without them? What purpose would it serve to keep them from their patients?

Just as the name infers, antibiotics are anti-bacterial. However, a sore throat or stomach sickness is often caused by a virus. A runny nose or sinus congestion can be caused by an allergic reaction. Foot infections are commonly caused by fungus. In these situations, what purpose would it serve to give an antibiotic? I hope it is clear that giving an antibiotic to kill a virus, fungus, or solve allergies is similar to using weed killer to kill cockroaches.

To make matters worse, misusing antibiotics can actually cause them to lose effectiveness when they are really needed. Bacteria are very smart little organisms. They are constantly changing so that they can better survive. We all have “normal flora,” otherwise known as bacteria that live in our intestines, on our skin, and in our mouth. However, these bacteria are kept in check by our immune system and by our protective layers of mucous and skin. By taking antibiotics when not indicated, we expose these bacteria to antibiotics. Instead of fighting the source of infection, some bacteria die but others are allowed the opportunity to develop protection against the antibiotics. So when you get a deep cut on your foot and those same bacteria are allowed to penetrate your body, the antibiotics may not be effective. For this reason, it is important to save the antibiotics we currently have for when they are truly needed. Your doctor is your best resource for knowing when they are to be used.

Nerves do pain, and more…

Ok, I know I said last week that we’re going to talk about a devastating foot condition caused by peripheral neuropathy this week, but I wanted to touch on another aspect of nerve dysfunction before we delve into it. So stay tuned….

We talked last week about high blood sugar in association with diabetes and how it damages the function of nerves. Specifically, we focused on how nerves lose the ability to sense pain. But nerves do a lot more than just sense pain.

Nerves are so smart that many of them function without us even knowing. Do you have to remember to keep your heart beating, or to keep your lungs breathing when you are asleep? Of course not! That is because nerves have an “autonomic” function (think of it as a nerve working automatically, without you needing to tell it to work). That is why you do not need to think about your heart beating or your lungs inflating. For this same reason, we do not have to think about digesting the food we eat, or moving the food through our digestive tract. It just happens.
Another important autonomic function of a nerve is its ability to control where the majority of our blood flows. During a marathon, blood is most needed in the muscles, heart and lungs. After a meal, blood is needed in the digestive tract to absorb essential nutrients. During an academic exam, the brain needs blood more than anywhere else. When you’re about to have sex… well… you get the picture. Depending on current needs, our body can shift blood flow so that it is used more efficiently. Just like losing pain sensation, high blood sugar can damage nerves so that they can’t perform their “autonomic” tasks.

Instead of food slowly but surely travelling through the intestines, it sits motionless in the stomach. Instead of bones getting the correct amount of blood flow, they are flooded with blood, making them soft and unable to handle the normal stresses of our weight. As nerve function continues to decrease, symptoms become worse and worse.
With that introduction, next week’s blog will focus on Charcot foot, a condition being seen more and more as diabetes spreads.

Charcot Foot (pronounced shar-co foot)

Our discussion regarding nerve dysfunction has culminated into this week’s topic. We’ve learned that loss of pain sensation and loss of autonomic (or automatic) function of nerves can be caused by diabetes. What happens if you lose both?

When nerves lose their autonomic ability to control blood flow to the bones in the foot, the excess blood makes the bones soft and unable to support weight. The minerals that keep bone strong are washed out and therefore, the bones become very weak. They cannot withstand the pressure that comes with walking around the house to do daily tasks. These patients tend to be overweight which only adds to the stress on the bone. The bones become deformed and the foot becomes unfunctional. This deformity is termed Charcot Foot.

As if that wasn’t bad enough, the people susceptible to Charcot foot are the same people who have lost their protective pain sensation. Even though their bones are being crushed and deformed with walking, they don’t feel a thing. For this reason, it may be weeks before the individual notices the bony bumps on their foot, and goes to see their podiatrist.

Charcot foot develops in stages. Initially, the foot will look swollen, red, and hot, but yet painless. This can be confusing because these symptoms are seen in other conditions like gout, osteomyelitis, and cellulitis, so it is important to seek attention immediately to make the correct diagnosis. If Charcot foot is diagnosed, it is imperative that you follow your podiatrist’s order to be non-weight bearing in a cast for a couple months. This spares the soft bones from being deformed. After the redness and swelling diminish, your bones begin to recover, and eventually they heal. If the patient has been dedicated to keeping weight off the foot, the deformity will be minimized, the patient can be fitted for a boot or shoes that will accommodate any bony protuberances, and reconstructive surgery can be avoided. If the patient has not been as compliant, the foot may no longer be functional and it will be at greater risk for friction ulcers forming where bone protrudes. Surgery will be needed to reverse the deformity, and foot functionality afterward is difficult to predict.

So what is the moral of the story? Nerve function is essential to healthy feet. You can minimize nerve damage by tightly controlling blood sugar. Keep an eye on those precious feet you have. Rub them and talk to them daily. If they look bad, but it doesn’t hurt, you know what to do. Your podiatrist will be waiting.

Sometimes Pain is Good

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

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

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

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

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

Pre-dislocation Options

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

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

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

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

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

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

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

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

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

Take 5!

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

There’s Such a Thing as a Total Ankle Replacement?

Within the last several years, although around for decades, Total Ankle Replacements have been gaining popularity in both the Podiatric and Orthopedic medical fields as a means of treating chronic ankle arthritis and pain. On the tails of success of the total knee and total hip replacements, used for treating painful hip and knee joints that have become chronically arthritic, technology for total ankle replacements has taken flight.

To many, understanding the science and theory behind total hip and total knee replacements makes sense and it seems as though these procedures have been around for long periods of time. Total ankle replacements have been around since the 1970’s and although they originally gained popularity in Europe, there are currently four Total Ankle Replacement systems that are FDA approved and available for use in the Unites States of America.

Indications for a total ankle replacement include ankle joints that have reached end-stage arthritis with chronic pain and have not responded to other conservative treatment options. Those ankles most likely to suffer end-stage ankle arthritis are ankles in patients who have a history of ankle trauma (fracture, joint infection etc) that has led to chronic pain. Conservative treatment options that may be explored prior to consideration of total ankle replacement include: joint injections, immobilization, physical therapy, and ankle scope.

In the past and currently, although times are changing, the ‘gold-standard’ treatment for end-stage ankle arthritis has been ankle fusion. An ankle fusion basically employs a cleaning up of the inside of the ankle joint followed by permanent consolidation of the bones that make up the ankle. The procedures end result is a permanent loss of motion at the ankle joint. If you prohibit motion at the ankle joint, or any joint with chronic pain and end-stage arthritis, you eliminate pain. A loss of motion = a loss of pain. However, with ankle fusion procedures, the motion lost (beneficial in the normal gait cycle), requires your body to make adjustments in gait. This inconvenience, for patients suffering from chronic pain and arthritis is nothing in comparison to the elimination of joint pain, and patients tend to do extremely well post-operatively. However, total ankle replacements aim to preserve ankle joint motion while still eliminating pain.

Preservation of motion while eliminating a patient’s pain would be far superior to ankle fusion, where motion is eliminated. Total ankle replacements are intended to allow the patient to ambulate with “normal” use of their ankle joint. If ankle replacements become the ‘gold standard’ of treatment in treating end-stage ankle conditions, they provide a viable option for patients before consideration of fusion.

Not all patients are candidates for total ankle replacement, so a discussion of all options should be explored with your Podiatrist. In addition, the technology is still expanding, but in the coming years it looks to be a promising alternative to treating patients with chronic ankle arthritis and pain.

Over the Counter “Custom Fit” Orthotic Inserts

Last week we talked about custom molded orthotic devices and the differences between those that are functional and those that are accommodative. Just as a reminder, functional orthotic devices are made to align the foot in a neutral position and work to support the surrounding structures, allowing the foot to function as normally as possible. Accommodative orthotic devices are indicate for patients with rigid deformities and accommodate the foot rather than attempt to realign it. A great example of the use of accommodative orthotics is in diabetic patients, as they will allow off-loading of high-pressure areas prone to ulceration.

We also briefly touched on the idea of “custom orthotics” being sold over the counter. If I didn’t make myself clear last week, let’s be clear this week: If you are purchasing something over the counter and off-the shelf in a drug store, they are not custom orthotics. Custom orthotics can only be manufactured in an orthotic lab using casts and/or scanned images of your feet, sent to the lab with specific manufacturing instructions from your Podiatrist.

What I want to discuss this week is the claim that such companies are making, like the newly advertised “Dr. Scholl’s Custom Fit Orthotic Insert Kiosk,” and what they actually mean when they say “custom fit.”

If you have yet to see the commercial, check out the Dr. Scholl’s website: http://www.footmapping.com/footmapping/about-the-kiosk/index.jspa

There, you can watch a video on how the Kiosk works and how it recommends which ‘custom orthotics’ to select off-the shelf. Let it be known that Dr. Scholl’s is not the only company who sells “custom orthotic inserts over the counter,” but it happens to be their commercial that sparked my writing about this topic.

Now, many of you might be confused, because this particular Kiosk “maps” your foot, similar to scanned images that might be taken by your Podiatrist if you’re set to purchase custom orthotics. This mapping allows the computer to understand the basic make-up of your foot and uses that information to generalize your overall foot-type. The kiosk will then suggest to you, based on the mapping of your foot, which Dr. Scholl’s “custom fit orthotic insert” best suits your generalized foot-type. You will be directed to either the left or right side of the Kiosk, where your ‘custom fit orthotic’ awaits you!

In reality, what this Kiosk is suggesting to you is what we as Podiatrist’s call, a Pre-fabricated Orthotic Device.” What that means is that those orthotic devices are manufactured to fit a generic foot-type. There might be one device that is pre-fabricated for a generic flat-foot and another pre-fabricated for a generic high-arched foot, but in no way is your foot, or anyone else’s foot generic. You have a specific foot that differs from each and every other individual, therefore, although these Pre-fabricated orthotic devices may help, they cannot be called “Custom Fit Orthotic Devices” because they were not made to specifically fit your foot.

Now with that said, if you remember back to last week, there are instances where as Podiatrist’s we will recommend an over the counter orthotic device to you. The recommendation depends on the deformity for which you present with in addition to whether the Podiatrist believes an over the counter, non-custom device will be beneficial. If they deem that an over the counter device would be suitable, or suggest such a device as a starting point, what you will be purchasing is a pre-fabricated orthotic device such as mentioned above at the Dr. Scholl’s Kiosk. It is not custom to your foot, but it may be sufficient enough to provide you significant relief.

Dr. Scholl’s is not the only company who manufactures such pre-fabricated devices; in fact there are hundreds of companies that offer these. You’re Podiatrist will most likely have a manufacturer who they particularly like and will recommend to you, should pre-fabricated orthotic devices be a viable option. It never hurts to mention or ask your Podiatrist about trying such orthotics prior to ordering a custom molded pair. As was mentioned last week, custom molded orthotics although necessary in some instances can be expensive, and we are not in the business of bankrupting our patients.

Functional versus Accommodative Custom Orthotics

I recently saw a commercial that was advertising a ‘Dr. Scholl’s Custom Fit Orthotic Insert Kiosk’ and I wondered, how exactly they were custom fit if there were only several inserts to chose from? It started me thinking about orthotics and how often the general public makes mention of them, but how little they generally know about their specifics. I wanted to take the opportunity, over the next several weeks to discuss what custom orthotics are and what you would be getting when you purchase something over the counter or from a Kiosk.

As Podiatrist we prescribe patients custom molded orthotics for a variety of foot ailments, but often, if we feel as though their condition would benefit from an over the counter orthotic insert, we start there. The one thing all patients and members of the general public can agree on is that custom molded orthotics can be expensive and are often uncovered by insurance companies. As Podiatrist’s we are not in the business of bankrupting our patients and thus if we feel that an over the counter orthotic would be sufficient enough to help your current condition, that is our first recommendation. However, there instances where we know that custom molded orthotics are the best option for you and the one that will provide the greatest relief, so in some circumstances they are our first recommendation.

There are two main types of custom molded orthotics that we prescribe, known as Functional and Accommodative orthotics. What people typically think of when they think of orthotics are those that are functional; coincidentally that type is the most often prescribed.

The general objective of any functional orthotic, regardless of the condition it is prescribed for, is to allow the foot to sit in as neutral a position as possible. By neutral position, what I’m referring to is the position of your foot where the tendons and ligaments surrounding the ankle are aligned in their most advantageous position, allowing the foot to function as “normally” as possible while eliminating compensation for any abnormality. In many conditions the orthotic is indicated to block abnormal motion of the foot by bringing the ground up to the foot (via the orthotic material) helping to decrease pain and deformity. To show the diversity of conditions for which functional orthotics can be utilized, a very limited list of conditions is detailed below:

Hallux limitus/rigidus
Pes plano valgus (collapsing/flat foot)
Cavus foot (high arched)
Limb-length discrepancies
Bunion deformities
Plantar fasciitis
Neuromas
Neuromuscular conditions

The objective of an accommodative orthotics is to accommodate the foot rather than to place the foot in a neutral position. These are often utilized in patients who have rigid conditions where the foot would not benefit from repositioning. Therefore, accommodative orthotic devices are prescribed for patients who need pressure alleviation at areas of high-pressure, such as diabetic patients with areas prone to ulceration. In such situations realigning the foot via the use of functional orthotics may do more harm to the patient than good.

Regardless of whether the functional custom orthotic or the accommodative function orthotic is utilized, they are both manufactured from a cast and/or digital image of your foot. Those casts or images are sent to a laboratory specializing in orthotic manufacturing and the custom orthotics come to life with adherence to specific manufacturing instructions from your Podiatrists. Custom orthotics are exactly that: custom to your foot through the cast or images sent to the orthotic laboratory. As we’ll discuss in the coming weeks, anything purchased over the counter cannot be custom if there are only a few varieties to choose from and if your “foot images” were not sent to a specialized orthotic laboratory for manufacturing of your orthotic devices from those images.

In efforts not to overwhelm you with the wealth of information regarding orthotics, we will stop here for this week. Next week, we will tackle the topic of over the counter orthotics versus those that are custom molded; how they differ and what those over the counter ‘custom fit orthotics’ really are.

Pretty in Pink…Nail Polish??

Summer is essentially here with the heat we’ve been having recently, thus men and women alike are flocking to nail salons hoping to perfect their toenails for sandals and peek-toed heels! This week we’re taking the opportunity to remind you of some ‘salon smart’ tips that will help you select a salon that’s clean so you receive that pedicure you’ve been craving, while keeping your risks of infection low!

1. Assess the salons cleanliness: Look around when you enter a nail salon and check to see if they have bottles of cleaning products near their pedicure soaking tubs. Are they cleaning out the tubs after each client? Soaking tubs are the areas in a salon that carry the highest risk of infection, so use caution! Have they autoclaved their tools between each client? The only way to ensure that nail tools are completely sterilized is through the use of an Autoclave (those little “hot boxes” where tools are placed between each client). Without Autoclave sterilization the tools are only “clean,” and may have lingering organisms present.

2. Purchase your own set of tools: Many salons provide clients the option of purchasing their own “nail tools,” for which you are the only client using those tools. Investing the extra few dollars on that first visit will provide you a decreased risk of infection and peace of mind, knowing that only those tools have touched your feet. You no longer need to worry about who’’s toes were being worked on before yours, and what “bugs” may be passed from them on to you.

3. Ask the salon personnel NOT to push back your cuticles: The nail cuticle is one your body’’s protection mechanisms for keeping bacteria out. By pushing the cuticle back, you open up the possibility of infection, as bacteria can now enter underneath the cuticle. Interrupting the natural function of your cuticles combined with un-sterilized tools and dirty soaking tubs is a sure bet for infection!

4. Give your toenails a rest: Frequently taking off nail polish and allowing the nails to “breath” helps prevent extra moisture from building up under the nail, subsequently decreasing your risk of infection by bacteria or fungus. In the winter months when sandals are infrequently worn, try to go without nail polish as much as possible. In the summer, when you know you won”t be on vacation or won”t need your nails looking “pretty in pink” for a certain event, take the polish off and give your toenails a break.

5. If you”re diabetic, pedicures are NOT recommended: As mentioned above, dirty tools, soaking tubs, and interrupted cuticles all combine to create a high risk for infection. The risk of infection from a pedicure is the same for clients with and without diabetes, but in the diabetic, the healing potential can be significantly decreased. Due to the nature of diabetes and the course it takes within the body, blood supply to the toes may be decreased, and without adequate blood flow, the cells in your body that fight infection are less likely to reach the site. This can lead to an infection that, in severe cases, runs up the foot and leg and if not caught early and treated aggressively can lead to loss of toes! In addition, healing potential for diabetics is decreased and for the same reasons infection takes a greater toll; the cells in the blood needed for wound healing are less likely to reach the areas where they are needed. In short, if you”re diabetic, it’’s wise to avoid pedicures at a salon. Instead, do your own pedicures at home where you can be sure everything is clean and leave your cuticles intact.

Hopefully these tips will pop into your head as you contemplate your next pedicure. It’’s important for feet to look nice for the summer months eliminating embarrassment with sandals where toes are exposed, but it’’s more important to avoid infection and its long-term complications!

How Did You Get Osteomyelitis?

Last blog entry gave a very brief overview of some of the more common imaging studies that Podiatrist’s tend to order to help them confirm their diagnosis. It reading that blog, your interest may have been peeked when the idea of bone infection was introduced, as it was discussed under several of the imaging modalities since bone infection can be captured in various ways. This week, I hope to indulge your newfound interest and provide some insight into the topic of bone infection. This topic is not an easy one to broach, as there are many questions when dealing with bone infections that must be answered. The why and the how of bone infection in a patient can sometimes be very clear-cut and in other patients, can be quite a mystery. The key, however, in treating bone infections is prompt diagnosis!

Let’s break it down a bit:

What is a bone infection? Bone infection, more commonly referred to as Osteomyelitis (Osteo = bone; meylo = marrow; itis = inflammation) is exactly as it sounds. Infection, much the same as would present in the skin, invades into bone allowing bacteria to thrive and wreak havoc. The severity of the bone infection depends on a number of variables, some of the more important of which are: how much bone is infected, the condition of the surrounding soft tissue structures, if the infection has traveled to other areas of the foot and leg, and the health status of the infected patient.

Who gets bone infections? Patients who are at a higher risk include those who have suffered an open fracture (one where the skin was opened upon fracture of bone) and those who present with chronic (long standing) open and infected foot ulcerations/wounds. However, anyone can suffer from osteomyelitis. In reactivated forms of osteomyelitis, bone infection occurred years ago but the infection suppressed by the body; secondary to trauma to the previously infected area, reactivation can occur.

When should you become suspicious of a bone infection? Those patients who should have the highest index of suspicion for a bone infection are those patients who are at a higher risk (i.e. open fracture patients and those with long standing infected wounds). If you are being treated for a long-standing non-healing wound, additional imaging studies may be recommended to rule osteomyelitis in or out. In a healthy patient signs of infection include redness, swelling and heat in the suspicious area, but in those patients with chronic wounds and a compromised immune system, such as Diabetics, those same symptoms may never present themselves.

Why is early recognition key? Early recognition is key so that initiation of treatment is prompt. The earlier bone infections are diagnosed, the better the treatment outcomes. The worry is that bone infections will continue to spread to adjacent bones and additional soft tissue structures causing larger infections that are more difficult to treat with antibiotics alone.

Where is the most common location in the foot and ankle? The most common location of osteomyelitis in the foot is underneath the metatarsal heads. The metatarsal are the long bones of the foot that connect to the toes. The location of the metatarsal heads is in the approximate area of the fat-pad of the forefoot. This area is most commonly affected because the metatarsal heads are under high pressures throughout gait.

How do we treat bone infections? Treating bone infections is very tricky and among other things, Podiatrists must carefully consider each patient before deciding on a treatment regimen that is best for that particular patient. Almost all patients will be placed on antibiotics, but depending on the severity of the infection depends on if those antibiotics will be administered in pill form or via an IV (intravenous) infusion. If you have a bone infection, expect to be on antibiotics for 4 weeks at the very least, but typically longer courses are required. If a bone infection has become so severe that antibiotics are only effective in keeping the infection at bay but will not eliminate the bacteria from the body all-together, surgical intervention is usually necessary. Surgery entails finding the source of the infection and any collections of infectious fluid and draining them, in addition to washing-out all the surrounding soft tissues and removing any bone that is dead/dying.

Osteomyelitis can be a scary and tricky diagnosis to face, but conversations with your Podiatrist (should you be diagnosed) can be very informative and will lead you towards the most appropriate treatment path with the greatest outcome for healing!

Imaging, Imaging and More Imaging!

As Podiatrist’s we order A LOT of imaging studies for our patients. Such studies include x-rays, MRI’s, CT Scans, Bone Scans, and Ultrasound to name a few. It may sometimes seem unnecessary and annoying because treatment is occasionally postponed until the results of such studies are received, but I assure you, they have their purpose. This week, the intent is to briefly describe some of the imaging studies we order, why we order them and how they differ from each other. However, it should be understood that we do not arbitrarily order imaging studies to help us come up with a diagnoses, but rather we use them to confirm our suspicions of a diagnosis.

X-rays: This is typically the first imaging study that will be performed by your Podiatrist. X-rays primarily capture the bones of the foot and ankle and for this reason, they are typically ordered for fractures, bunions, hammertoes, and any pathology that may disrupt the bone including diffuse bone infection, bone tumors, gout and arthritis to name a few. They also allow us to take a closer look at the position of the bones during stance, providing a snapshot of how your foot functions during gait (walking). X-rays, although they can’t specifically convey information about the soft tissues (muscles, ligaments, tendons) they can show swelling, which most often correlates with a clinical picture. Finally, they can show calcified vessels: blood vessels in the lower extremity that have become hardened and thus indicate poor blood flow to the lower extremity. Limitations to x-rays, as mentioned above include soft tissues structures, which need further imaging studies for complete evaluation. In addition, x-rays have a lag time in recognizing stress fractures and acute (early) bone infection. For a plain x-ray to show either of those two pathologies, the pathology needs to have been present for about 10 days; long enough for significant bone destruction (50%) to be visualized on x-ray. For that reason, with a high clinical suspicion of either of those two pathologies, additional imaging studies are typically performed.

MRI’s (Magnetic Resonance Imaging): If we want to get a better picture of soft tissue structures including muscles, tendons, and ligaments in the lower extremity, MRI’s are a good option. MRI’s have the ability to hone in on inflammation within or surrounding a tendon and clearly show ruptures of such structures. They focus less on bone pathology when referring to fractures (CT’s are more accurate), but they are superior to CT scans in diagnosis bone infection (osteomyelitis). The reason being that they provide excellent visualization of the medullary canal of the bone (the central area where bone infection tends to migrate), and thus help Podiatrists determine how far the infection has spread and how aggressive their treatment regimen needs to be. Finally, they are the best option diagnosing pathology between bone and soft tissue, where it needs to be determined if bone pathology has spread into adjacent soft tissues and vice versus. The only downside with MRI usage is that, should a patient have any metal or stainless steel anywhere in their body, these studies cannot be performed as they interact with the magnets within the MRI machine.

CT Scans (Computerized Tomography): These scans are excellent for visualizing bone to a greater degree than standard x-rays can show us. Often CT Scans are ordered for evaluation of complex fractures such as Lisfranc fractures and calcaneal fractures. They can more accurately show fractures too small to be visualized on plain x-ray in addition to helping to determine the amount of joint surface involved in the pathology. CT scans can also be used in diagnosis of bone infection, but MRI’s are typically a better option as they can more accurately capture the medullary canal. CT scans can be used in patients with metal or stainless steel implants, thus are a good alternative for patients who can not undergo MRI evaluation.

Ultrasounds: This imaging studying is becoming more and more popular among Podiatric Physicians, whereby diagnosis of various pathologies can be made through its use. The test takes little time, making it more convenient for the patient in addition to providing quick results to you Podiatrist. Ultrasounds are very useful for tendon pathology, meaning any deformity or abnormality in a tendon, such as rupture, tear, or inflammation surrounding a tendon, which indicates aggravation of the tissue. These studies are also becoming more popular for use in diagnosing neuromas (inflammation of nerve tissue in the web-spaces) and have provided use in guiding injections of the foot for more accurate medication placement.

Although it can seem burdensome, imaging studies do help us confirm our suspected diagnoses and are often necessary for treatment to begin, so we appreciate you taking the time to have them completed per our request. The hope is that you now have a greater understanding of each of the imaging modalities discussed above, and can thus understand why we request them to be performed. Certainly, each type of imaging study discussed above encompasses a broader range of uses, but those discussed this week are the primary reasons for viewing in the foot and ankle.

It’s Really Not a Bunion?

A bunion and HL/HR are two different conditions and although patients often confuse them, it’s important when presenting to a Podiatrist that the conditions are separated from each other, as etiology and treatment different.

Hallux limitus is a restriction or limitation to motion of the great toe joint that results mainly from biomechanical abnormalities of the foot. As the condition, progresses the joint motion becomes so restricted that motion at the great toe joint ceases all together, resulting in a condition called hallux rigidus. After a complete evaluation of the involved foot, your Podiatrist will discuss all treatment options for HL and HR with you, most often suggesting treatment options that are first conservative. We mentioned several of those options last week including orthotics, joint injections and padding of the toe to decrease pressure in the area of concern. When conservative treatments have been attempted and exhausted without resolution of symptoms including pain and discomfort in the great toe joint, surgical options can be explored.

As with any surgical procedure, your Podiatrist will review your x-rays, re-examine your foot and recommend a surgical procedure most appropriate for the status of your HL/HR condition that aims to decrease your current level of pain. In treating HL/HR there are 3 larger categories of surgical procedures that we will briefly discuss; the first two options, in order to decrease your current level of pain, aim to decompress the joint to accomplish this goal. Decompression allows for the creation of a larger space between the two bones that make up the great toe joint therefore, allowing greater motion and less jamming between the two. You and your Podiatrist will discuss the options and determine which is the best option for you.

1. Joint Cleaning: The first procedure attempts to enter the great toe joint and clean up the area between the two involved bones. Any inflammation within the joint is removed, any boney spurs are shaved down and smoothed off and the joint is closed. This procedure is typically reserved for patients in the early stages of HL/HR development and often provides great relief. Removing any spurs and inflammation decompresses the joint, allowing for greater motion. Recovery is generally short, approximately 2-4 weeks, as only soft-tissues need to heal before activity can be resumed.
2. Bone Cutting Procedures: This category encompasses several different types of procedures, but all accomplish decompression of the great toe joint with the result of greater motion and decreased pain by surgically cutting one or both of the bones making up the great toe joint. The procedures aim to lower and slightly shorten the 1st metatarsal to create a larger joint space. Be aware, fixation including pins and screws may be utilized! These types of procedures are typically reserved for patients with more advanced HL and recovery time is typically longer versus joint cleaning procedures (closer to 6-8 weeks), because the surgery is more involved and needs to allow significant time for the bone to heal.
3. Fusion: A fusion procedure of the great toe sounds just as it is; the great toe joint is fused whereby motion at the joint is surgically eliminated with the use of pins and screws to hold the toe in its desired position. As we mentioned last week, if there is no motion, there is no pain! This procedure is reserved for “worst-case” patients and those who have unbearable pain at a young age and is considered a definitive procedure. Recovery is longer than even the bone cutting procedures to ensure that complete fusion has take place before weight bearing can begin.

As with any surgical procedure the risks and benefits should be considered and discussed with your Podiatrist before any decisions are made. Complications with any of the HL/HR procedures described above can include infection, scarring, recurrence of deformity, and transfer pain among others, although the risks of any such complications are minimal. The object of both conservative and surgical treatment options is to decrease pain and increase motion at the great toe joint while keeping you on your feet!

10 Fingers and 10, no wait…11 Toes?

Polydactyly, the name that classifies the condition of having more than 5 fingers on a single hand or more than 5 toes on a single foot, is condition usually recognized at birth. The condition is traditionally hereditary and in most cases can be visualized by the presence of an extra digit at the time of delivery. As we’ll discuss, there are varying types of accessory (extra) digits with some types non-visible and only discovered with x-rays of the foot sometime later in life.

In most cases, polydactyly is a cosmetic anomaly and presents no immediate pain or health concerns for the patient. The most involved digits are the “postaxial” digits: those digits located towards the outside of the foot. They are referred to as the “postaxial” digits relative to their position during prenatal growth, but in terms of treatment and management, this designation means very little. In half of those who are diagnosed with polydactyly, the extra digit will be present bilaterally; meaning on both feet, such that the patient may be born with 12 toes. The demographic most associated with polydactyly are African-Americans, but the diagnosis is not exclusive to that population.

As mentioned above, there are varying types of accessory digits and they are so classified according to which bones in the foot are duplicated, contributing to the extra digits presence. In addition, the classification also notes the shape of the metatarsal (long bones in the foot) and how it has accommodated to allow for the extra toe. Keep in mind when trying to understand this classification system that each digit (2-5) is made up of one metatarsal and 3 smaller bones referred to as phalanges. As Podiatrists, we typically classify into 5 categories:

Normal metatarsal with duplication of two of the three phalangeal bones, contributes to the presence of two toes, neither with the correct number of bones to create a completely “normal extra digit.”

Wide (Block) metatarsal whereby the metatarsal is widened but not duplicated. The widened portion of the metatarsal accommodates for duplication of all three phalangeal bones, yielding two “normal” toes.

Y-shaped metatarsal. Rather than the metatarsal widening, the portion of the metatarsal bone closest to the toes splits, forming a y-shaped bone. Again, this allows for duplication of all three phalangeal bones and the presence of two “normal” toes.

T-shaped metatarsal. This is much the same as the y-shaped metatarsal, but rather than looking like a “y,” the metatarsal bone looks more like a “t,” still allowing for duplication of all three phalange bones and the creation of two “normal toes” versus the traditional one.

Complete duplication is present when the metatarsal bone and all three phalangeal bones are duplicated, such that a single foot has 6 metatarsal bones (versus the traditional 5) and 17 phalangeal bones (versus the traditional 14).



Now that you’re an expert at the polydactyly classification system, and would be able to diagnose any x-ray where extra digits were present (just kidding!), lets briefly discuss how it’s treated! As mentioned above, polydactyly presents no immediate pain or health concerns to the patient, but it can complicate issues of self-confidence and present an annoyance when attempting to buy shoes. Therefore, if present at birth, the extra toe is usually removed at birth and never mentioned again. However, if it is not removed at birth or if an incomplete form of polydactyly is present where an extra digit isn’t noticed at the time of birth but extra bones are present within the foot, the extra bones may be dealt with later in life.

When polydactyly occurs your Podiatrist must first evaluate your foot with x-rays to determine which of the 2 copies of a single toe has the most potential for normal growth. Once they’ve identified which of the two will grow most normally, they will address the copy of that digit and usually opt for amputation. Amputation is a scary word and can often be associated with massive infections and commonly as a diabetic complication, but here, if the patient is in good health otherwise, amputation will be tolerated quite well. Since there is already and extra digit present, when removed, it should not affect function of the foot, and the normal amount of toes remain!

Although we hope that each new baby is born with only 10 fingers and 10 toes, if presented with a newborn that fashions 11 toes, we will know how to treat him/her!

Oh No…What About the Growth Plate?

Whenever you hear of a child suffering from an injury, automatically your mind wanders to the topic of growth plates. We always wondering if the growth plate is affected; the concern is legitimate and needs to be thoroughly evaluated upon presentation to the doctor. When dealing with lower extremity injuries the Podiatrist will x-ray and clinically evaluate the injury to determine if the area in and around the growth plate is affected but the actual “plate” unaffected, or if the injury has directly disrupted the growth plate itself. The treatment plan changes from initial management to the possibility of surgical management and the choice of fixation (pins/screws etc) that can be utilized depending on the extent of growth plate involvement.

When understanding a pediatric injury versus the same injury in an adult, there are some important concepts to understand. The first is that in kids, the bones are very malleable meaning that the tendons and ligaments surrounding the bones, helping with normal motion are stronger than the actual bones themselves. Therefore, in a pediatric patient injury is likely to lead to bone injury versus in an adult where the bones are stronger, ligament damage is more likely. Secondly, treating injuries or fractures in the pediatric patient are much more complicated because of the presence of the growth plate.

Growth plates in the lower extremity, when visualized on x-ray, indicate that growth of the individual is still possible. When evaluating bones on x-ray, there are specific “zones” that can be identified to signify growth, disruption of growth and healthy bone. What you may not know is that when born, the bones are very soft and malleable and only harden (ossify) and change completely into solid bone in a child’s mid to late teens and sometimes not until their early twenties. What this indicates is that injury anywhere in the body, before ossification takes place, can affect growing bone with the possibility of disrupting growth, causing abnormal/irregular growth and even has the potential to halt growth altogether.

In an adult, the growth plate has closed, growth has ceased and treatment of a fracture can be initiated without fear of interrupting growing bone. If pins, screws or plates are needed for fixing the adult fracture, they can be applied without reservations or worries of disrupting growth. However, in pediatric patients certain types of fixation must be avoided and others used carefully and in specific ways so as to protect the growth plate and allow for normal growth to continue.

When the growth plate is unaffected fracture management is tricky, but can be more easily handled and the growth plate more easily avoided during treatment. When fracture across the growth plate is created by the initial injury the goal of fracture management becomes more complicated as the growth plate cannot be avoided during treatment. It must be addressed with reduction and fixation bringing the edges of the fractured growth plate into close proximity with one another. Doing so decreases the risk of interrupted or halted growth in the affected bone with the hope that restoration of normal growth occurs.

Pediatric fractures can be tricky, but they can be treated in such a way as to minimize disruption to normal growth patterns. It is important to seek treatment immediately if fracture is suspected, but refrain for pondering the worst-case scenario until your child has been evaluated!

Please, check your feet!!

Diabetic neuropathy is one of the most common complications that as Podiatrist we see in our diabetic patient population. At this time of the year it is very important to review neuropathy, its causes, and the importance of daily foot checks at home to prevent complications associated with having neuropathy.

Neuropathy by definition is disease or dysfunction of one or more peripheral nerves that typically causes numbness, weakness, or both and generally begins in the extremities, especially a patient’s feet. It is thought that a combination of factors adds to the incidence of neuropathy in diabetic patients, but it is directly related to poor sugar control. Nerves are very sensitive to changes in blood glucose levels and when consistently high, the sugar molecules tend to glycosylate (collect on) both the small blood vessels and the small nerves. This glycosylation compresses the nerve to some degree and results in the symptomatic representation of neuropathy.

Several categories of neuropathy affect the diabetic population, but the most common type is Peripheral Neuropathy. Peripheral Neuropathy is also known as distal symmetric neuropathy, meaning symptoms present first in the toes and fingers on both the right and left sides of the body. As the neuropathy progresses it continues towards the arms and legs; centrally on the body. The sensory changes are minimal at first and may go unnoticed, but as the neuropathy progresses symptoms become more discernable. The best was to prevent and control the progression of diabetic neuropathy is to keep your blood glucose levels within normal range, thus protecting your nerves from glycosylation.

Comprehensive foot examinations by your Podiatrist can help diagnose peripheral neuropathy in its early stages and it is important to remember that if you are experiencing any changes in sensation to your toes or feet, you see your doctor immediately. Your Podiatrist will look for changes in light and sharp touch, vibration sense, reflexes and your ulceration risk. All of these components can hold clues to an early diagnosis of peripheral neuropathy.

Whether you’re newly diagnosed or have been dealing with neuropathy for some time, you must be doing your part at home! Checking your feet every night, identifying any open areas on your soles or between toes and any color changes that may indicate problems is imperative. The largest complication associated with having diabetic neuropathy is the patients inability to feel, thus injuries that would be painful in a non-diabetic go unnoticed in a diabetic and can lead to ulceration, infection, and loss of digits. If you notice something unusual or different from the previous day, contact your Podiatrist for an appointment. As the weather gets warmer, it’s especially important to wear closed-toed shoes only, much for the same reasons as mentioned above. Open-toed shoes open the door for more injuries, more bacteria to cultivate on your foot and larger problems. Although it might not always be ideal, it is always safer!!

What about white vs. colored socks?
This is a question we get a lot from our diabetic patients with neuropathy: why white socks over colored? The answer is non-scientific and has nothing to do with dyes in the socks that may be harmful (in fact, unless a patient has an allergy, dyes are not typically harmful). Rather, the answer lies in the fact that white socks can serve as an indicator for patients. When patients can’t feel their feet, white socks, when removed at the end of the day can be inspected for signs of staining, blood or openings that may indicate injury to the foot. They prompt the patient to explore further whether they need to be following up with their Podiatrist for problems with their feet.

Whether you’re a diabetic patient with or without neuropathy, it is important to have occasional screenings conducted by your Podiatrist helping to catch complications early and decrease risks associated with your disease!

What to Expect When a Stray Bullet Comes your Way!

Gunshot wounds are rarely injuries that present to a podiatric practice, but they do occur and they can affect the lower extremities. However, when dealt with by a podiatrist, it’s typically in the hospital setting, where the Podiatrist has been called in during the middle of the night to see a patient in the emergency room. Hopefully this type of injury is not one that you can relate to, but as we are tackling uncommon injuries and diagnoses this month I thought it fitting to discuss this type of injury. We will only scratch the surface in discussing such injuries with the hope that you’ll never need to know the rest!

When a patient presents with a gunshot wound/injury, as Podiatrist’s we will interview the patient to determine how the injury occurred, but the answer is usually unimportant and unrelated to the treatment protocol that will be followed; the opposite of how we handle most other injuries where the mechanism is extremely important. With gunshot wounds, there’s been an injury, the damage needs to be assessed, we need to determine if the bullet or any pieces of the bullet remain in the patient, and construct a course of treatment.

Assessing the damage. Typically the emergency room doctors will treat any injuries, in addition to the gunshot wound that are life-threatening to the patient or need immediate attention. This includes a complete workup of the patient to determine if they have stable vital signs (heart rate, blood pressure etc) and any injuries to their head, abdomen, chest etc. Once any initial threat to the patient is dismissed, the Podiatrist is called in and needs to assess any damage specific to the area of injury. In past blogs we’ve talked about compartment syndrome and neurovascular compromise, and those are the two most important things that will be immediately deciphered. Does the patient have pulses to the foot below the level of injury? Is the sensation in the foot the same in comparison to the non-injured foot, below the level of the injury? Has the injury in some way blocked blood flow and/or caused compression or severance of any nerves in the foot. If the answer to any of these questions is yes, the situation becomes more urgent. If the answer to all questions is no, then the situation is less urgent, but still needs significant evaluation and treatment.

Where’s the bullet? A bullet and any pieces that may remain from the bullet (if there are any) will show up on x-ray. Therefore, x-rays in the area of interest are routinely performed on patients with gunshot injuries/wounds. Once it is determined that there are no pieces of the bullet remaining in the patient, treatment can progress. If the bullet is lodged or if there are pieces present, the location needs to be determined, as it will affect treatment. As a general rule, and for simplicity purposes if the bullet is lodged securely in the bone without fracture to the bone, it is left alone. If the bullet is in the surrounding tissues, it is typically removed and all pieces if accessible through the open wound are removed. If pieces are not accessible, they are left alone.

What’s the next step? Gunshot wounds, independent of a graze vs penetrating vs through and through injury need to be cleansed thoroughly once the initial damage has been assessed and all immediate concerns such as compartment syndrome and vascular compromises have been handled. Thorough cleaning entails a trip to the operating room where all dirt and debris brought into the area by the bullet are removed with high-pressure application of sterile solution, decreasing the risk of infection. Depending on the Podiatrist’s experience, the type of wound, and the surrounding skin, the wound may or may not be initially closed with sutures. Often times, the wound must be left open and allowed to fill in with new skin and tissue on it’s own because the edges of the affected area can not be brought back together.

Gunshot wounds are uncommon injuries and are complicated in their treatment. The Podiatrist must ask him/herself numerous questions to determine the best course of treatment for each individual patient so that they are given the best chance at a complete recovery. Although this is a simplistic view of what Podiatrists are faced with when dealing with this type of injury, it does provide some insight.

Steer clear of flying bullets and you’ll never need to see this information utilized first hand!

A Marathoner’s Nightmare!

After working in the medical tent at the Boston Marathon this past Monday, I’ve come to two conclusions:

A. I will never run a marathon. As a member of the medical team I saw the worst of the worst, as athletes piled in with chest pain, dehydration and electrolyte imbalances. Unfortunately, I didn’t get to see the thousands of runners who completed the race unscathed.

B. Blisters can be a marathoner’s worst nightmare, especially when they occur towards the front of the race, as with each step they are constantly reminding the runner of their presence!

The root of all evils when it comes to blister formation is moisture. Blister formation occurs when friction and moisture combine separating the top layer of skin (epidermis) from the second layer of skin (dermis) allowing the area between to fill with fluid. Typically, the fluid within a blister is clear (serous), but can be bloody or filled with infection. Even if you’re not running marathons, the following “Blister Tips” address some of the myths of blister care, guiding you towards appropriate treatment.

1. Don’t pop blisters at home! It can be rather tempting to pop a fresh blister and relieve the pressure by expressing the fluid, but that’s not recommended. Blisters, by nature, contain sterile fluid, meaning that there is no bacterium inside and infection is a remote possibility. If you decide to pop a blister with a needle that you might have “sterilized” in your bathroom, you run the risk of introducing infection. Resist the urge to pop your blister and allow your body to resorb blister fluid on its own.

2. If I shouldn’t pop blisters at home, why did the medical staff pop them during my marathon? In an acute setting, such as during a marathon, blisters are typically popped by the medical staff. The reason: immediate relief of the excess pressure allows runners to continue through the remainder of the competition. The medical staff cleans the skin surrounding the blister with alcohol, uses a sterile needle to puncture the skin, and drains fluid out at it’s lowest point of gravity. Although the method isn’t perfect, and not recommended at home, the medical staff does their best to prevent infection while providing immediately relief for the athlete.

3. What to do if your blister pops on its own: As mentioned above, once your blister is exposed to the outside environment, infection becomes a possibility as there is now an entry point for bacterium. When this occurs, you need to do your best to keep the blistered area extremely clean. Using warm water and soap is sufficient, making sure to dry the area thoroughly and protect it using a band-aid that covers the entire blister. Avoid using hydrogen peroxide to cleanse the area. If dead skin remains, leave the skin in place, as it is still capable of providing a barrier for infection while providing a good environment for new skin to grow underneath.

4. Get your feet measured for shoe-size accuracy. As we’ve mentioned, blisters are mainly caused by friction combined with moisture. Shoes that are tight in the wrong places can cause recurrent irritation and frequent blistering. Getting your feet measured for an accurate shoe size can make a difference if you’ve been wearing the wrong size! Adjusting your running shoes to fit your feet may also increase your distance and comfort level while engaging in activity.

5. Blisters can occur separate from friction and moisture. Blisters that are small in size and seem to continually appear for unexplained reasons may indicate a problem separate from friction and moisture. Check the other areas of your feet looking for scaly skin on the soles and heels. If you find areas of scaly skin, it is likely that you have a fungal infection and the blister formation is a result of that. Contact your Podiatrist for an appointment, as they can treat your fungal infection quickly with topical medications!

6. Prevention is your best option! The goal in prevention is to decrease friction and eliminate moisture, as those are the most common predisposing factors. As discussed wearing shoes that fit your foot is important in decreasing areas of pressure where friction is imminent. In addition, keeping your feet dry and wearing socks that allow the feet to breath, versus cotton socks that hold in moisture, is very important. Finally, treating any underlying conditions such as fungus that may be causing blister formation will help tremendously in prevention.