Does Foot Surgery Cause Blood Clots?

Advancements to surgical techniques have allowed doctors to fix problems that previously were unable to be solved.  This has led to longer and better quality of life in hundreds of millions of people.  However, surgery is not benign.  There are many potential risks associated with any surgical procedure, and foot surgery is no exception.  One of the many potential risk is the formation of deep vein thrombosis (DVT), otherwise known as a blood clot.  Let’s discuss some of the ways to reduce the risk of forming a DVT.

Before we get too far along, it is important to know that blood clots after foot surgery are very uncommon.  That being said, it is still important to know what can be done to reduce the risk of blood clot formation and how to treat them, since they can have life threatening effects.

Unfortunately, there are some risk factors that we cannot change which increase the risk of DVTs.  Older people tend to be at greater risk than younger people.  Women also are more likely to have a DVT when compared to men.  If you inherited a blood clotting disorder, or something like that runs in your family, you also have increased risk of DVT.  These risk factors cannot be changed, but it is important that you understand their significance before surgery.

Fortunately, there are several risk factors that can be modified so the risk of DVT is lessened.  Obesity, sedentary lifestyle, and use of tobacco are all associated with increased DVT risk.  Specifically with foot surgery, being confined to a bed or wheelchair will immobilize your leg, which decreases blood flow and can increase the risk of DVT.  Thankfully, all of these risk factors can be addressed.  Before surgery, if a person was able to lose weight, increase their activity, and temporarily refrain from using tobacco products before and after the procedure, their risk of DVT would dramatically decrease.

Now that we understand the risk factors associated with blood clots, we will discuss in the next post how to recognize the signs and symptoms and appropriate treatment.

Knock Knees and Bow Legs in Children

As we discussed last time, parents understandably seem to very sensitive to any apparent deformity or perceived imperfection in their children as they develop.  Another common concern for parents is if their children walk with their knees touching or with their legs bowed.  Let’s discuss some of the important points regarding this subject.

Some of the principles we discussed in the toe walking post also apply to this discussion.  Abrupt changes or a sudden deviation from the normal over a short period of time are the best indicator of an underlying problem.  When children are learning to walk, they will find the easiest, most comfortable way to get around.  This tends to not be the most normal looking gait cycle.  Unless they were walking in one way and abruptly change, variations from “normal” should not be alarming.

As a child matures, their bones go through an unwinding process.  This process is called torsion.  As the bones unwind, a child’s gait will slightly alter until the maturation process is a finished.  Depending on the age of the child, their legs will vary from being slightly bow legged to slightly knocked kneed and somewhere in between.    This evolution of the legs tends to resolve at about the age of fourteen, with the legs being straight or very close to it.

Parents should seek medical attention if the deformities are severely exaggerated in either direction.  Most often, severe walking deformities can be expected with some childhood neurological disorders and are often caught close to the birth of the child.  However, they can develop later unexpectedly due to an underlying bone disorder or malnutrition due to malabsorption of a certain nutrient.  These are less common but do happen.

We’ll talk about another pediatric condition in our next post that if treated immediately can be completely reversed without any residual effects.

Clubfeet and their Treatment

Staying in the thread of pediatric conditions, clubfoot is a deformity that should be addressed.  Although it is rarely seen in adolescents and adults in our country, it occurs in about 1 in every 1000 births.  Fortunately, it is recognized very early and treated immediately when seen in the United States.  With immediate appropriate treatment, a person born with clubfoot can expect to walk normally without residual effects.

Clubfoot is when the front of the foot has turned in and wrapped itself around the back of the foot so that if the child were to walk, they would have to bear weight on the thin skin of the top of the foot rather than the thick skin on the bottom of the foot.  The foot is described as being shaped like the letter “C” turned in on itself.  Clubfoot is a deformity seen with some neurological disorders, but more often it is seen simply due to lack of room.  The lack of space pushes the feet up against the wall of the uterus.  When the baby is born, the deformed feet are easily recognized.

Fortunately, a baby’s body is very flexible after it is born, and remains very flexible while the mother is breast feeding.  This flexibility allows us to mold a clubfoot back into proper position without major surgery.  Starting as soon as possible, the baby is put into a series of casts, removed and reapplied each week, which will slowly bring the foot back around so that it will eventually function as a normally.  Within 12 weeks, a severely deformed foot can look completely normal.  The body’s ability to adapt and remodel is incredible at that young age, and we can take advantage of this by immediate treatment.  The babies who do the best are the ones who are treated only hours to days after birth.  If treatment is delayed for weeks or months, the baby may not be flexible enough to resolve the entire deformity.  If this is encountered, surgery may be required for correct the problems.

Toe Walking in Children

As parents, we are very concerned about how our children develop.  One thing that seems to push parents to seek a medical profession is how their child walks.  Is toe walking bad?  Does it mean that they will walk like that forever?  Is it a sign that something else may be wrong?  Let’s discuss.

Toe walking in and of its self is harmless and in most cases is simply how your child has decided to walk.  Many children simply have chosen to toe walk because it is comfortable for them at this stage.  If the child has been walking on their toes since their first step, there is additional assurance that nothing is wrong.  If the child is old enough to respond to verbal commands, ask them to stand on their heels and to walk with their heels touching the ground.  The far majority of children will be able to do this easily and painfree.  This is a sign that there is no underlying problem or surgical issue that needs to be addressed. 

Toe walking is only a sign of an underlying disorder when it is accompanied by other signs of slow development, or if the child was walking on their heels and then suddenly begins to walk on their toes.  If the child is missing other milestones of growth, cognitive development, or other benchmarks, a pediatric physician should be consulted.  If the child was walking normally and then begins to toe walk, or if they begin to toe walk only on one foot, this should also prompt evaluation.  Pinching of the spinal cord from a myriad of possible sources could be the reason and can be addressed and reversed.  It is possible, however,  that the abrupt toe walking is a sign of a muscle or nerve development problem that may not be so easy to reverse.  This represents a very small percentage of cases which your child most likely does not fit into.

In most cases, toe walking is not a sign of an underlying problem, and parents can be assured that their child will walk normally eventually.  We’ll discuss some other common worries parents have for their young children in future posts.

Treatment for Heel Pain in Kids

Last week we discussed Sever’s Disease, or calcaneal apophysitis, which is the major cause of heel pain in children.  Let’s now discuss how to help.

The most immediate relief can be gained by taking an anti-inflammatory medication like ibuprofen.  This will help take the edge off the pain and allow them to continue to participate in athletic events.  A higher dose of ibuprofen needs to be taken in order to have the pain relief.  Pediatric doses depend on the weight of the child and their ability to swallow pills.  This can have an very beneficial effect in a very short time.

Another easy thing that can be done it for the child to wear heel lifts.  A major component to the pain is the pull of the Achilles tendon on the growth plate.  Especially taut Achilles tendons must be relaxed in order to decrease their pull.  Heel lifts can take the tension off of the Achilles and allow the inflammatory process at the heel bone to calm down.

Achilles tendon stretching is the treatment which takes longer to have an effect, but will result in long term relief.  Stand facing a wall with feet facing forward and shoulder width apart.  Take two steps backward.  With one foot, take one step toward the wall, while keeping the other foot 2 steps from the wall.  Lean forward and place both hands against the wall while keeping both keep pointing forward.  This should cause the Achilles tendon in the foot furthest from the wall to be stretched.  This should not be painful, but should stretch the tight tendon.  Hold this position for 30 seconds then switch feet.  Do this at least 5 times a day, more if possible.  This will help to eventually eliminate this problem so that heel lifts and medication are no longer needed.

The combination of the previous treatments should help to resolve the heel pain in a matter of weeks, so that children can maintain their active lifestyles.

Heel Pain in Kids

Kids have an incredible ability to deal with pain.  I’ve seen young children take bad falls, run into walls, or accidently get hit by a flying object and not miss a beat.  They are stunned for a second, might shed a quick tear, but before you know it, they are back running around having fun.  Despite their ability to play through discomfort, there is a specific type of heel pain that seems to bring kids to the doctor that we should discuss.

In order for a child’s bones to grow, the body forms a “growth plate” which allows bones to grow in length.  These growth plates stay open into a child’s teenage years, allowing for maturation of their bodies.  These growth plates are very sensitive to injury and are easily irritated.  In a child’s heel, there is a growth plate which is commonly irritated as a child becomes more active in sports.  The Achilles tendon is attached to this growth plate, which leaves the growth plate susceptible to the strong pull of this strong tendon as the bone grows.   This is a very common condition in kids, which is called Calcaneal Apophysitis, or Sever’s Disease.

Symptoms that most children will experience are heel pain toward the end or after playing sports.  There may be some mild swelling, but no bruising and the child will not be able to recall a specific event that caused their heels to hurt.  Pain will slowly go away with rest, but will return if participation in sports is re-started.  Sever’s disease is very commonly seen at the beginning of a new sports season, when wearing tight cleats or new athletic shoes,  or when suddenly increasing activity after a relatively less active time period.  Most children will recognize that something is not right and complain of their feet hurting.

Thankfully, this condition is very common and is not associated with long term foot pain.  With some slight modification to shoe gear and other minor changes, most children will be pain free in 2-4 weeks and not miss any part of their athletic season.  We’ll discuss treatment options next post.

Surgical Treatment of Warts

If conservative treatment for warts is unable to effectively kill the virus, or the warts seem to recur frequently to the point that weekly visits to the podiatrist for the next couple months are needed, it is reasonable to pursue surgical removal.  Although the warts can come back, this is an effective method of treatment. This can be accomplished in different ways.

The simplest way to achieve wart removal is simply to cut it out.  If there are only a couple warts and if they are not too deep, this can be done with local anesthetic in the office.  A small amount of numbing medicine will be put around the wart to make the procedure as painless as possible.  The procedure is done with a scalpel and a curette, which allows the podiatrist to completely remove all virus infected tissue.  A small dressing and some ointment will then be applied and need to be changed for the next couple weeks while the wound heals.  The location will be tender for the upcoming weeks, so wearing a special shoe that off loads the area may be more comfortable.

If the wart is too deep or the involvement is too wide spread, it may be necessary to be taken to the operating room for removal there.  The procedure is the same as outlined above; however, the patient is sedated in addition to the local anesthetic to decrease the amount of pain.  This allows the doctor to be more aggressive to insure complete removal of warty tissue.  Cautery and/or lasers are now often used to burn the edges of the previous wart to kill any additional virus left behind.  This process of curettage, followed by cautery, then repeating the cycle can be very effective in killing the virus.

Although warts are certainly not life threatening, if they are found on the weight bearing surface of the feet, they can alter your activities and decrease your ability to experience painless exercise.  Talk to your podiatrist if you are struggling with recurrent planter’s warts.  Together, you will find a solution to the problem.

Warts Treatment Continued

Wart treatment continues to develop and newer treatment modalities continue to come out.  Let’s discuss some of the more popular treatments.

The reason why warts persist so long is that they hide from the immune system by living in the thick skin of the plantar skin.  A popular theory now being investigated is injecting something into the wart that will alert the immune system.  Candida albicans, a yeast known for causing oral thrush and yeast infections, has been injected into warts.  The immune system then begins to attack the yeast, and at the same time realizes the presence of the wart and begins to attack it.  This treatment has shown promising results in some, but doesn’t work for everyone.  Talk to your podiatrist if you are interested in attempting this mode of treatment.

Another treatment for warts is called bleomycin.  This may alarm some of you who know that this medication is a chemotherapy agent for those undergoing cancer treatments.  However, when using this medication for wart treatment, bleomycin is diluted down and is only injected into the most superficial part of the skin, similar to how TB tests are done.  Bleomycin stays locally inside the wart and does not get into your circulation.  After one application, the wart will turn black over a 2 week period.  The wart is then debrided using a scalpel.  Often, only one or two treatment is necessary.  If used correctly, this treatment is very effective in only a few office visits.

Another product being used for wart treatment is canthacur.  This is a product that comes from the saliva of an exotic beetle.  It is a very potent chemical that when applied to skin will cause blistering and lifting of the skin, which will cause the wart virus to die.  This is a newer treatment that is slowly gaining favor.  The most commonly seen problem with this treatment is that the chemical, when the foot begins to sweat, will dissolve and not stay over the affected area.  This will obviously decrease the effectiveness of the treatment.

If these conservative measures fail, there are some surgical options that can be pursued.  We’ll discuss these next post.

Warts Treatment

Warts have become so common that health professionals use a myriad of treatments, not to mention home remedies and folk remedies that are shared on personal blogs and websites alike.  We’ll go over some of the more common treatments used by professionals, and mention some of the more popular home recipes.

The best treatment for any condition is prevention.  The best way to prevent picking up the virus is to wear footwear in public areas where water is present.  Be especially careful around locker room showers at health clubs, or at public swimming pools.  If you have an open cut or a break in the skin, be especially cautious.  If you think your shower may be contaminated, a dilute bleach cleaning solution will be sufficient to remove the virus.

A common treatment used by podiatrists is salicylic acid.  This acid works by slowly eating away at the skin infected by wart.  The acid is in a cream form, is applied every week for 5-6 weeks, and is covered with a strong adhesive tape such as duct tape to ensure the acid stays in the correct spot.  After each treatment, the dead skin is shaved away with a scalpel to get to the deeper skin where the wart is hiding.  This is an effective, painless way to get rid of a plantar wart.  The downside is that it requires consistent office visits over a couple weeks.

Another common treatment for warts is cryotherapy, or freezing the warts.  By using a very direct freezing solution, you can induce a local frost bite on the wart, causing the skin and therefore the wart to die.  Similar to salicylic acid, this is a treatment that needs to be applied several times over a couple weeks.  A common mistake when using this treatment is that the cryotherapy is not applied long enough to penetrate the thick skin of the plantar skin.  In order for freezing to work, the therapy must be applied long enough for the treatment to be painful.  For this reason, podiatrists are using this therapy less and less.

We’ve only scratched the surface of wart treatment.  We’ll discuss some more next post.

How did I get this wart?

Summer time is slowly coming to an end, a time of year that many kids spend endless hours at the pool.  It is normal to get a few bumps and scratches along the way, especially on the toes and feet.  Breaks in the skin allow potential viruses to get into the skin and grow.  One of the most common viruses found in this environment is the virus that causes plantar warts.

Verrucae, commonly known as warts, are the result of an infection of a virus, which is part of a family of viruses called the human papilloma virus or HPV.   If that sounds familiar to you, it is because this family of viruses is responsible for cervical cancer and gential warts.  Thankfully, when concerning the manifestation of warts on the feet, they are benign and will disappear on their own without any treatment in a couple of years.

The virus is confined to the thick skin on the soles of the feet, which while it keeps the virus from spreading, it allows the virus to hide from the immune system.  This allows the virus to grow and seed on the plantar skin.

How can we tell a wart from a simple callus or IPK?  When shaved with a small blade, a wart will have small distinct pores that will bleed, a phenomenon termed “pin point bleeding.”  In addition, the skin lines on the soles of the feet will be interrupted by the growth of the wart.  Another way to correctly diagnose a wart will be to squeeze the wart between your fingers.  This will induce exquisite pain, more so than if direct pressure is applied to the surface of the wart.

As you probably know, this is a very common problem among children and young adults.  As such, there is no end to the many treatments that have been attempted, some more successful than others.  We’ll discuss the possible treatments in the upcoming posts.

PTTD Surgical Treatments

Once conservative treatments have failed in treating posterior tibial tendon dysfunction, surgery can be looked at as a potential way to reduce pain and correct the collapsed arch.  There are a wide variety of procedures that have been used.  Some involve repairing tendons or other soft tissues.  Others involve making cuts in bone to shift their position to reestablish their correct position.  If there is cartilage damage or arthritis in the joint, fusing the joints may be beneficial.  We’ll discuss each category of procedures.

Before any surgical decisions are made, an MRI should be ordered and reviewed with your doctor.  With the help of an MRI, the entire length of the posterior tibial tendon can be analyzed and the extent of damage can be determined.  If cartilage damage is present, this will be obvious on the MRI images.  MRI is an important tool that is essential for determination of the best procedure.

If the condition is not too far advanced, a soft tissue procedure can be done to help stop progression of the problem.  This may involve repairing the damaged tendon, or transferring a healthy tendon to take its place.  In some cases, using a tendon graft can help strengthen the tendon.  The nice thing about these procedures is that once the incision is healed (about 2 weeks), you can walk on the foot which was operated on.

If the condition is too far advanced, a soft tissue procedure will not be powerful enough to correct the problem.  In such cases, bone must be cut in order to re-align the foot under the body.  These procedures provide more correction than the soft tissue procedures.  In situations where cartilage damage is present, the surgeon may choose to fuse the damaged joint.  Although these procedures are more definitive and have more potential benefit, the recovery time is much longer.  When bone is cut, the patient should be non-weight bearing for up to 6 weeks to allow the bone to heal in proper position.  Additional non-weight bearing time may be necessary depending on how fast each particular patient heals.  The doctor will want to see you every 2-3 weeks to take xrays to insure proper healing.

PTTD is a difficult condition to treat.  Discuss with your podiatrist which procedure option best suits your situation.  Most patients see dramatic reduction in pain and a foot that allows for normal ambulation.

PTTD Conservative Treatments

Once diagnosed with Posterior Tibial Tendon Dysfunction as evidenced by the “too many toes” sign and the heel rise test, there are some conservative treatments available to help support or slow the progression of the condition.  The best treatment for you will depend on how far advanced you are with the disorder.

If caught far enough in advance, minor modifications can be made to shoe gear to help reduce the amount of pronation.  Custom orthotics made from plaster molds can be fashioned to give support to the arch.  Modifications can be made to the orthotics with time.   If pain persists, a steroid shot can be given to help decrease inflammation.   The decision to go ahead with a shot must be carefully considered as steroids can weaken ligaments and cause the condition to progress faster.  Oral steroids or anti-inflammatory medication may provide some relief, but will not reverse or halt the progression.

In most cases, orthotics will not provide enough relief.  In many instances, orthotics are skipped as a treatment and the doctor will recommend a custom ankle brace as the primary treatment.  Similar to orthotics, you will be casted for the brace, which will then be sent off to a lab for fabrication.  There are many variations to this brace, and they will be fabricated slightly different.  This brace laces up the front, extends up around the ankle, and fits into most shoes.  It helps to give support to the arch and foot.  Movement of the joints in the foot is minimized, thus reducing pain and swelling.  If worn consistently, this brace can be a definitive treatment for some individuals.  However, the brace can be bulky and difficult to wear during the warm summer months.

Despite our best efforts, some patients will eventually exhaust conservative treatments.  At this point, surgical options are explored.  Your doctor will probably order an MRI to get an idea of how degenerated the posterior tibial tendon is.  This will help the doctor to recommend the best surgical option.  We’ll discuss these options next post.

Signs of Flatfoot (PTTD)

We discussed last week the development of flatfoot in adulthood.  There are some diagnostic signs and tests that your podiatrist uses to determine if you have the condition, as well as how far the condition has advanced.

Pain along the course of the posterior tibial tendon is the most important sign when diagnosing PTTD.  The posterior tibialis tendon wraps around the inside of the ankle and inserts on the arch.  This allows the muscle to support the arch.  If there is pain at the tendon’s insertion or pain when the doctor palpates the tendon as it goes up the leg, you may be experiencing PTTD.  If there is no pain, PTTD is unlikely.

Assuming there is pain along the tendon, there are other tests that can be done to help confirm the diagnosis.  The doctor will have the patient stand facing the wall.  The doctor will stand directly behind the patient.  Normally, the doctor can only see the 4^th and 5^th toes, with the leg covering the rest of the toes.  In PTTD, when positioned behind the patient, the doctor will be able to see almost all of toes.  This is known as the “too many toes” sign.

Another test your doctor will use to grade the amount of dysfunction is called the heel rise test.  The doctor will have you stand next to the wall or counter for balance.  You will then be asked to stand on your toes, first each foot individually, then both feet together.  In someone with PTTD, this will illicit large amounts of pain in the arch and up the leg.  In more advanced situations, the patient will not be capable of lifting their heels off the ground at all.  Patients often are surprised that they didn’t notice their inability to lift up on their heels before their appointment.

Lastly, the doctor will watch you walk in the office.  This is called gait analysis.  The “too many toes sign” will be seen as they walk.  The heel bone will not have normal movement, and the person will practically be walking on the inside of the foot, the arch being completely absent.  The doctor will then correlate these findings to the x-rays taken in order to suggest the best treatment options.  We’ll discuss some of those treatment options next week.

How Did My Foot Become So Flat?

It is a normal phenomenon for the foot to get larger over a lifetime of use.  Ligaments lose their tensile strength and tendons can lengthen over time making the shape and size of the foot change.  However, these changes happen over a long period of time, making them unnoticeable from month to month.  The only situation is which noticeable changes happen normally would be in pregnancy, since women have hormones in their body which are meant to make ligaments more flexible to allow for child birth.  But have you noticed that your arch has slowly but noticeably flattened over a period of months?  If so, you may have a condition termed Posterior Tibial Tendon Dysfunction or PTTD.

The posterior tibial muscle is the main muscle that supports the arch of the foot.  The tendon runs on the inside of the leg right behind the inside of the ankle.  It is the main muscle that allows you to turn the sole of one foot in so that it is facing the other foot.  In certain foot types, this muscle can be subject to a significant amount of force, causing over lengthening and breakdown of the tendon.  If the tendon degenerates or loses its strength, the muscle loses its ability to hold the arch up.  With time, the arch slowly loses its height, causing pain and difficulty fitting in shoes.  This process may not produce enough discomfort to push you to see a podiatrist until some irreversible damage has already been done.  There are different stages of PTTD, thus the treatment depends on how degenerated the tendon is.  In most cases, an MRI is needed to assess the current status of the tendon.

There are a couple tests that we can do in the office to assess if PTTD is present, and if so present, how far advanced the condition is.   This helps to determine which conservative or surgical options may help.  We’ll discuss these clinical tests in the next post.

Ankle Sprain Surgery

As mentioned before, the overwhelming majority of ankle sprains will get better with conservative care in 2-3 months.  Once x-rays have confirmed there isn’t any fracture, most sprains get better with R.I.C.E., as well as bracing and protection.  However, there are some people who will continue to have pain and discomfort despite our best efforts.  The decision to go ahead with surgery is one that is complicated. Both the patient and doctor will have to discuss and agree upon a plan as a team.  Let’s discuss some options.

One attractive option is to do ankle arthroscopy.  Similar to what is done in the knee, a small fiber-optic camera is inserted into the ankle joint along with a tool to remove any loose particles inside the ankle joint.  With multiple ankle sprains, pieces of bone, cartilage, or inflamed ligaments can impinge on the ankle joint.  Once loose particles are removed, pain is lessened and improvement is seen.  The main advantage to ankle arthroscopy is that there are only 2 small incisions made where the instruments are inserted.   The incisions heal quickly and downtime is usually 10 days to 2 weeks.

Another procedure that can be done is called a Brostrom procedure.  As we discussed, ankle sprains can cause ligaments to tear.  The Brostrom procedure attempts to sew back together a ligament that is often torn in ankle sprains.  It is sewn together with a very strong suture material, so that stability is gained and pain is minimized.  This procedure requires a longer healing period as the ligament fiber ends need to reconnect.'

In some cases, torn ligaments are so bad that it is impossible to sow them back together.  In these cases, grafts can be used.  There are many variations to what can be done to recreate the ligaments.  The doctor can use a graft made from bovine or porcine sources, or harvest tendon from another source in the body.  Depending on which ligaments are torn, the doctor can adjust what he uses to restore stability.

There are additional procedures that exist to help a persistent ankle sprain.  Work with your doctor to decide which procedure best fits your situation.

Ankle Sprain Conservative Treatments

We talked last week about ankle sprains, how they happen, and what conditions predispose someone to getting one. Let’s now discuss some of the initial treatment available. Fortunately, most ankle sprains will eventually resolve without long term issues. When compared to bone or muscle, a ligament’s blood supply is significantly less. Since blood carries oxygen and healing factors within it, blood supply partially determines how fast an injury heals. For this reason, ankle sprains heal slower than bone or muscles, resulting in about a 6-8 week heal time. A person can usually engage in full activity 3 months after the initial injury. Conservative treatment for ankle sprains is what you might expect with any foot injury. After making sure there are no fractures with x-rays, ankle bracing, ankle taping, short leg casting, protection, RICE (rest, ice, compression, and elevation), anti-inflammatory shots, and anti-inflammatory oral medication have all been used to treat these types of injuries. A common regiment for treating ankle sprains is RICE for 2-4 days, followed by ankle bracing and strengthening exercises for a couple weeks. Once you can weight bear without discomfort, a short regiment of physical therapy will help you to regain confidence in the ankle. You’ll notice that with the exception of physical therapy and anti-inflammatory shots, most of the treatments mentioned can be obtained over the counter. So you might wonder why you need to see your podiatrist. The reason is simple. What may feel like a simple ankle sprain might actually be an ankle fracture. In some cases, an ankle sprain might actually have damaged cartilage in the ankle, or broken one of the leg bones (the fibula) up close to the knee. If these injuries go undiagnosed and undertreated, there may be some irreversible damage done. Although a simple ankle sprain is more common, these other injuries happen often enough to warrant evaluation by a doctor. If pain persists despite conservative measures, or you are someone who has chronic ankle sprains, surgical options may need to be discussed. At this point, the doctor will probably request an MRI to assist in planning what operation needs to be done. We’ll discuss these options next post.

What Do Podiatrists Do?

Podiatrists have long been known to be the people to see for ingrown nails, hammertoes, and heel pain.  But today’s podiatrist does much more than that.  Let’s first talk about their education, and then what that allows them to do.

To become a podiatrist, after high school, a person must attend an undergraduate university and receive a 4 year bachelor degree.  Most choose to major in a science related major, such as biology, chemistry, exercise science, physiology etc…  By completing these degrees, they have taken the necessary courses to prepare to take the Medical College Admission Test (MCAT).  An applicant then submits their college transcript along with their MCAT score to a podiatric medical college.  Although separate from MD medical schools, podiatric medical school’s curriculum is held to the same standard of other doctorate level medical programs.  After 4 years of medical school and passing of board exams, a person must then complete a 3 year residency program at a hospital somewhere across the country.  During these 3 years, a podiatrist receives their surgical training.  And at last, once licensed, a person can then practice as a podiatrist.  All in all, a licensed podiatrist receives at least 11 years of additional education after high school.

As academic standards and competitiveness have increased, the level of training has also increased.  Today’s podiatrist can still trim calluses and nails of high risk patients like diabetic like we always have.  But they are also trained to fix ankle fractures, repair Achilles tendons, and even put a camera into the ankle joint and clean it out like an orthopedic surgeon commonly does to a knee.  Just like in many medical specialties, some podiatrists like to focus their efforts in pediatrics, athletes, or geriatric patients.  Even if the podiatrist you are seeing doesn’t routinely treat your current condition, he/she surely knows of another podiatrist in the community that does.  

Ask your podiatrist what he can treat.  You’ll be pleasantly surprised what they can help you with.

Bone Scans

The last imaging technique we’ll discuss will be different types of full body scans available, specifically used by podiatrists to determine if bone infection is present.

A scan, either for bone or WBCs (white blood cells), is done by injecting a very small amount of a specific type of radioactive dye into a vein.  This dye will then spread through the body as the blood is pumped through all the bone, muscle and internal organs.  The dye contains a certain substance that will bind to somewhere in the body.  The dye for bone scans binds to bone that is currently being remodeled.  The dye for WBCs will search out WBCs and bind to them.  The person is then scanned at different time intervals with a gamma camera, which is able to detect where the most activity is concentrated.   This can be very useful in diagnosing foot conditions.

When it comes to podiatry, these scans are primarily useful with diabetic patients.  Diabetic patients struggle with two conditions, osteomyelitis (bone infection) due to ulceration, and Charcot Foot (a non-infected bone destructive process).  These two conditions are sometimes difficult to tell apart clinically.  With infected bone, both a bone and WBC scan will be positive, whereas only a bone scan will be positive with Charcot.  Bone scans can give the podiatrist clues to which process if going on.  Scans are generally cheap tests and readily available.

A downside to bone scans is that they are not very specific.  There are many conditions that will have a positive bone scan.  A fracture, infected bone, growth plates, arthritis etc. will all give positive bone scans.  So even if I suspect bone infection, and the bone scan comes back as positive, I still have to perform other tests to confirm my suspicions.  There could be another underlying condition giving the positive bone scan test.  This obviously limits their usefulness. Some types of scans are technically difficult to perform, and others are difficult to read.  Scans also expose the patient to some radiation, thus making it necessary to make sure these scans are not ordered unless absolutely necessary.

Imaging techniques used by podiatrists are essential in determining the source of patient’s complaints.  These techniques are very safe when used in the appropriate situations. 

Podiatric CT Scans

We’ve discussed some of the more well-known imaging techniques used by foot doctors to help understand and diagnose foot pain.  There are additional tests that podiatrists use less routinely, but nonetheless give important information in the right circumstances.  Let’s discuss CT scans and their use in podiatry.

If you remember when we discussed MRI, we talked about how a magnet is used to take sequential slices through the foot, which are then grouped together to give a three dimensional image of foot.  CT scans are similar in that they take slices of the foot like an MRI.  However, instead of using a magnet, CT scans use a computer that generates x-rays.  Whereas regular x-rays only give a two dimensional image, when grouped together, CT scan can give a 3D image. 

CT offers some very useful advantages over other imaging techniques.  CT scans allow incredible visualization of bone.  In cases of high impact injury like falling from tall heights, or dropping a heavy object on the foot, bone can fracture into many small fragments.  In many of these cases, surgery is required to fix the fractures.  CT scans can help the surgeon to know before surgery how many fragments there are and where they are located.  This allows the surgeon to plan in advance how to best go about repairing the fractures, and to make the most appropriate decisions for the patient.

CT scans do have some limitations.  The main disadvantage to these scans is the amount of radiation the patient is exposed to.  When compared to a single x-ray, a CT scan exposes you to several times over the amount of radiation.  For this reason, in podiatry, they tend to be ordered with very badly fractured heel or ankle bones.  Although CT scans can differentiate between bone, tendon, and muscle, MRI gives a much clearer picture of these structures without exposure to radiation.

In our next post, we’ll discuss bone scans, another type of imaging that can be useful in diabetic conditions and infections.

Advanced Imaging: MRI

Prior to now, we have discussed ways a doctor can get an image of your foot in the office.  However, as we discussed, there are times when a more advanced and detailed image is needed.  Magnetic Resonance Imaging (MRI) is a great tool to use in these situations.

In order to obtain an MRI, a patient is placed in a room with machine containing a giant magnet.  This magnet causes the hydrogen ions in your bones, muscle, and other soft tissue to give off a signal that can be detected by a computer.  Depending on the tissue, different signals will be given off.  The computer analyzes the signals and develops a picture.  Once the 1^st picture is taken, the machine moves a couple millimeters and takes the next picture. If you can imagine slicing up a tomato or onion, an MRI is like slicing the foot into many individual sections.  These individual slices are then grouped together so the doctor can get a good picture of the inside of the foot.

The major benefit to an MRI is that it can show bone, tendon, and cartilage in a very detailed image.  This can be used by the doctor as a surgical planning tool before he takes a patient to the operating room.  MRI can be helpful to diagnose a condition, but most problems can be diagnosed during a routine office visit without the help of an MRI.  Although there are exceptions to that rule, an MRI is not usually ordered until the doctor and patient have agreed that surgical treatment is needed.

Another benefit to MRI is that no radiation is received by the patient, and it does not require a dye or contrast to be injected into the patient.  MRI is a completely noninvasive imaging technique.  For these reasons, MRIs are very safe for the patient.

On the other hand, an MRI requires you to lie motionless for an extended period of time.  If you are moving when the slices are being taken, the image becomes distorted and impossible to interpret.  This can be somewhat uncomfortable.  In addition, if you have metal plates or screws in your body from previous surgery, the metal will distort the image, making it hard to see anything.  For that reason, some patients may not be able to get a useful MRI.  Lastly, MRIs are very expensive.  Most insurance providers will not pay for an MRI until multiple conservative measures have been exhausted with no improvement in treating the patient.

MRI is a valuable tool that has helped doctors see subtle problems that x-ray and ultrasound miss.  It is primarily a surgical planning tool to help surgeons be more prepared before surgery.  However, it must be used appropriately so not as to waste resources.

Podiatric Ultrasound

I’m sure many of you hear the word “ultrasound” and correlate it with pregnancy and gynecology, but ultrasound is a very safe and useful tool podiatrists have to visualize and diagnose the source of a patient’s pain.  Let’s discuss some of the pros and cons of ultrasound.

First and foremost, ultrasound is very safe to the patient.  Ultrasound is simply a machine that sends out sound waves at a certain frequency, which then forms an image from how the waves bounce back.  Most importantly, no radiation or tissue damage occurs from these sound waves.  This is supported by multiple studies and its long and continued use in visualizing babies in utero.  This long history of safety has led to the development of ultrasound machines specifically made to see bone, tendon, and ligament.

Secondly, ultrasound gives a real-time image.  X-rays, MRI, and CT scans are frozen images.  Ultrasound gives a “living image” so that as the patient moves the foot, the image reflects that movement.  This gives the doctor more information on how the foot is functioning as it moves.  Without this insight, the doctor might miss the true source of the pain.  Ultrasound can be used to visualize bone as well as soft tissue.  In addition, when giving an injection, the doctor can give it under the guidance of ultrasound.  This can help the doctor insure that the medicine is being placed in the area of inflammation.

Lastly, ultrasound is inexpensive and convenient.  Ultrasound machines for foot and ankle imaging are very small and can be moved from exam room to exam room very easily.  When compared to CT scans and MRI, ultrasound is much cheaper and therefore, insurances are more likely to cover the cost.  Ultrasound does not require a dye to be injected into your veins (often needed for CT scans), neither does it require you to lie motionless (as is needed with MRI).  All in all, is a very cost effective way to diagnose foot and ankle conditions.

The main disadvantage to ultrasound is that it requires a trained eye to both know the mechanics of the machine and to read the ultrasound image.  Only after much experience can a technician consistently read an ultrasound accurately.  Your podiatrist will be able to correctly interpret your ultrasound.

Now that we have covered the ways to image the foot and ankle in the office, we will discuss the more advanced imaging techniques of CT scans and MRIs in our next posts.

Podiatric Imaging - X-rays

With the exception of dermatology, most doctors are treating conditions that they cannot see with the naked eye.  In order to overcome this hurdle, many different types of imaging techniques and instruments have been developed in order to allow the doctor direct visualization of the problem area.  Let’s discuss the imaging most often used in podiatry.

The most commonly used imaging technique in podiatry is radiographs, or x-rays.  Although there are many exceptions to this rule, most people who walk into a podiatrist’s office will get x-rays.  X-rays are the best to order when a patient’s main complaint could potentially involve the bones or joints.  X-rays give only two dimensional images, so it is necessary to take x-rays from multiple angles so that the doctor can mentally put the images together to form a three dimensional picture.  X-rays give the doctor important clues in figuring out the pain a person is experiencing.  Fractures, foot mal-alignment, and arthritis can be diagnosed with simple x-rays.  If a person has stepped on a foreign object, x-rays can help to locate the position of it.  X-rays also can help to push the doctor to order additional tests or refer out to a different specialist if certain signs are present suggesting disease like rheumatoid arthritis, peripheral arterial disease, or other systemic disease.  It may even be necessary to get an x-ray with a severely infected ingrown toenail to see if the infection has gotten into the bone.

 

A concern that some patients have is the radiation associated with x-rays.  This was a problem in past decades with more primitive x-ray machines.  However, modern x-ray machines minimize the scatter of x-rays by directing the beams directly at the target object and having a very short exposure time.  Lead is worn to protect against the small amount of scatter.  X-rays are avoided if the patient is currently pregnant.  You can be assured the amount of radiation received by the foot is very small.  In fact, an x-ray exposes you to the same amount of radiation you would receive by spending about 5 minutes in the sun.  When compared to tanning, sun-bathing, or going without sunscreen in the sun, the radiation of an x-ray is insignificant.

Even though x-rays show bones and joints very nicely, they do not show much in terms of muscles, tendons, ligaments, or blood flow.  In some complicated fractures, it may be hard to determine the extent of the fracture with only an x-ray.  In these cases, ultrasound, Magnetic Resonance Imaging (MRI), computed tomography (CT or CAT Scan), or bone scans may be used.  We will discuss each of these imaging techniques in the upcoming weeks.

Wound Debridement Continued

Let’s finish our discussion on the different types of debridement.

Mechanical debridement is another method to remove non-viable tissue. This is accomplished by applying wet to dry dressings. Normal gauze is soaked in some type of antibacterial solution and packed into the wound. Solutions may be simple saline, Dakin’s (a diluted version of bleach), or other antibacterial solutions. This wet gauze once packed into the wound is covered by dry gauze then wrapped. This dressing is changed every day. As the packed gauze is removed, dead tissue is removed with it. This is a very inexpensive way to keep a wound clean, ward off infection and allows for evaluation every day during dressing change. This dressing may be used prior to application of a Negative Pressure Wound VAC. However, dressing changes may be a very painful as they rip superficial tissue off.

Autolysis is another option for debridement. Autolysis means to let the body digest or get rid of bad tissue by its own means. The body produces digestive enzymes called MMP’s. MMP’s at the wound’s surface liquefy the dead tissue. In order to allow the MMP’s to work, an occlusive dressing is placed over the wound. Occlusive dressings are not permeable to air and they keep the wound isolated from the outside environment. Occlusive dressings are relatively controversial. Some feel that occluding a wound keeps fluid and possibly unknown pus in a wound. However, studies show occluding a wound keeps its pH low, which inhibits bacterial growth and promotes oxygen unloading from red blood cells. Autolytic debridement is a more advanced way to debride a wound and requires frequent evaluation and inspection.

All in all, each method of debridement has its place in wound therapy. Different physicians prefer different dressings depending on their experience and training. If you are currently working to heal a wound, work with your doctor to know which type of debridement is best for your situation.

Debridement of Diabetic Wounds

In light of our recent discussions on maggot therapy, I thought it would be wise to discuss different ways to debride diabetic wounds and their associated pros and cons. Wound care is continually being assessed for effectiveness and continues to evolve. This is a short review of some of the many options available.

The most obvious way to debride a wound is manually with a curette or scalpel blade. This is the mainstay of wound debridement due to its practicality and ease. This type of debridement can be done quickly in an office visit or bedside without any major equipment. It is cheap and fast and allows for evaluation immediately after. In more recent times, debridement using a machine producing sound waves has been used bedside to remove dead tissue. However, there is no evidence showing that it is more effective than a scalpel blade.

Surgical methods are another way to debride wounds. This is usually reserved for unusually large or chronic wounds that need deeper or more radical debridement. Instruments like the VersaJet combine manual debridement with highly pressurized water to remove non-viable tissue. The benefit of surgical debridement is that the patient is sedated so the doctor can be more aggressive and insure all dead is tissue removed. However, taking the patient to the operating room, needing medical clearance and the assistance of an anesthesiologist makes surgical debridement less practical and is only used if medically necessary.

Another type of debridement is use of ointments that contain enzymes that breakdown dead tissue. This is especially useful in situations where a patient has full sensation to the wound. Manual debridement may prove to be too painful for the patient to go through. In contrast, enzymatic ointments slowly dissolve making it painless for the patient. The downside of enzyme ointments is that they take longer to work. In addition, enzymes are very sensitive to small changes in pH, making it possible for them to be inactivated if the wound is too acidic or basic.

We’ll discuss mechanical debridement, autolytic debridement, as well as how wound care dressings can effect debridement in our next post.

Medical Maggots continued

As more and more patients have difficult wounds to heal, we have looked to the past and brought back more primitive yet effective ways to clean and close wounds. One of these techniques is putting maggots into wounds.

Maggots are simply baby or immature flies. There are many species of flies, some of which are not beneficial for wounds. So it is not a good idea to go diving into dumpsters trying to find a nice batch of them. Special pharmacies have them available for wound care clinics and hospitals. Once ordered, they can be shipped overnight and ready the next day for application.

Once the maggots are placed in a wound, precautions need to be taken so that they do not escape. A mesh net is put over the wound, and the wound is surrounded by a very adherent material. This keeps them in the wound so that they can deliver maximum benefit. The maggots will then secrete enzymes that dissolve the dead and non-viable tissue at the wound’s surface over a couple days’ time. Once dissolved, the maggots consume the components of the dissolved material. After a couple days in the wound, the maggots can become much larger then when they were put in. They are removed from the wound to assess if they did their job well. It may take a couple of treatments of maggot therapy to remove all the dead tissue.

Another great benefit of maggot therapy is that it can be combined with other wound treatments without caution. Antibiotics, hyperbaric oxygen, and even wound VACs (vacuum assisted closure) can be used after maggots to increase the chance of healing.

Although putting eventual flies into a wound may not seem very cutting edge or fancy, some treatments stand the test of time. Maggot therapy can help wounds to heal and prevent amputations of the foot and leg. Ask your podiatrist if he feels that maggot therapy may be beneficial for the healing of your wound.

Medical Maggots

We have discussed extensively on this blog the devastating effects of diabetes on wound healing.  It can make sores that normally heal in days take months to heal.  The longer a wound stays unhealed and open, the greater chance of it getting infected and needing IV antibiotics at the hospital. 

Although the majority of wounds seen today are results of diseases like diabetes or venous insufficiency, that has not always been the case.  In past decades, the majority of wounds were related to war injuries.  In times of war, wounds were primarily results of bullets, explosions and shrapnel.  Back then, antibiotics has not been discovered and doctors were limited on how to clean wounds to prevent infection.  Most available treatments were harmful to both dead tissue and good tissue.  Many people lost limbs or even their lives from what would be considered today as minor wounds. 

Although there is documentation of maggots being used throughout history to help heal wounds, the first modern day use of them came during the American Civil War in the 1860s.  Doctors noticed that fly larvae seemed to leave good tissue alone and clean out only the bad.  Wounds treated with maggots seemed to heal faster and allow soldiers to keep their injured limbs.  Once antibiotics were discovered around the time of World War II, the combination of these two therapies proved to be a huge advancement in wound care.

In recent decades, maggot therapy has been used less and less as it seemed to be a very primitive form of treatment.  Obviously, the suggestion of using maggots to heal a wound has not been openly accepted by patients.   But when we remember that a diabetic’s immune system isn’t functioning properly, something has to be done to heal their wounds.  Maggots are now being used more and more to heal chronic wounds.  We’ll discuss how exactly maggots clean wounds in the next post.

Antibiotics Revisited

Several months ago we discussed on this blog the proper use of antibiotics for infections in the foot and leg. I wanted to revisit that subject somewhat by talking about three important points your doctor considers when deciding to give or not to give an antibiotic to you.

1. Antibiotics have not been shown to be beneficial for non-infected wounds.

The signs of infection are pain, swelling, redness, and warmth. If no signs or only one sign is present, the wound is probably not infected. In this scenario, neither oral or topical antibiotics have not been shown to help heal the wound. It has been thought that it would be good to preemptively treat the wound with antibiotics to ward off infection. However, this increases the chance of antibiotic resistant bacteria infecting the wound.

2. Mis-using antibiotics will decrease their effectiveness and increase their price

When antibiotics are used when no infection is present, the bacteria are given the opportunity to develop resistance to that antibiotic. Over time, as more and more bacteria develop resistance, a previously effective antibiotic may become useless. This will decrease the number of available effective antibiotics, thus driving up their price. New antibiotics take years to develop and will be slow to replace the ineffective ones.

3. When given antibiotics, make sure to take the entire dosage even if the infection is gone.

Even when the infection looks to be resolved, it is important to finish off the entire course of antibiotics your doctor has given you. They are dosed in a fashion to kill all harmful bacteria. If you stop taking them once things to be getter better, it gives the bacteria a chance to reproduce and develop resistance.

If your doctor decides against giving you antibiotics, trust in his/her judgment. However, if all the signs of infection or pus presents later, be sure to let your podiatrist know so that appropriate action can be taken.

3 things to heal a Diabetic Ulcer

Diabetic ulcers are becoming one of the major causes of amputation of a toe or limb.  A small sore can turn into a large wound in a very small amount of time.  If you are diabetic, it is important to seek proper care and precautions need to be taken in order to prevent ulcers and to stop an existing ulcers from progressing into uncontrollable wounds.  These precautions can be summarized into offloading, decreasing bacterial load, and insuring adequate blood flow.

Offloading simply means to not put weight on the ulcer.  Offloading is accomplished by wearing special shoes that allow you to walk, but decrease pressure on the ulcer site.  Excess walking will put pressure and friction on the wound site.  These forces prevent the skin cells from healing the wound.  If a diabetic with a history of diabetic wounds goes barefoot just once, an ulcer can open up in a short amount of time.

Moist, dead skin is a perfect environment for bacteria to multiply and potentially infect a wound.  By seeing your podiatrist regularly, this dead skin can be “debrided” or removed from around the ulcer.  This decreases the amount of bacteria threatening the wound so as to decrease the chance of the ulcer becoming infected.

Blood is the substance that contains all the growth factors and oxygen needed for the body to heal itself.  You may be confused to why you leave your podiatrist with your wound bleeding.  Debriding the wound not only removes dead skin, but it removes any dead material actually inside the wound to insure the base of the ulcer is receiving blood to its surface.

When these three precautions are met, ulcers tend to heal without complication.  With proper vigilance, a diabetic can avoid ulcerations and amputations altogether.

Diabetes on the Skin

As we discussed last time, several skin conditions are associated with the development of diabetes. They occur because the walls of our arteries become too thick to allow oxygen to pass and nourish the skin. Over time, the skin will weaken, get thinner, or even begin to die. Let’s discuss two common skin manifestations of diabetes.

Necrobiosis Lipoidica Diabeticorum is a common skin condition that occurs with diabetes . It presents as very large reddish- brown patch of skin on one or both shins. With time, it will grow in size and become yellowish and shiny in the center. If left alone, this brown patch of skin can ulcerate and become infected. As mentioned before, this condition may show up before somebody knows that they are diabetic. Unfortunately, this patch of skin does not necessarily go away once diabetes treatment has begun. However, it may alarm a person to seek evaluation by a physician.

Another skin condition associated with diabetes is Xanthoma Diabeticorum. Xanthoma refers to fat that may deposit just under the surface of the skin. They appear as unexplained little yellow bumps. In the development of diabetes, there is a phase where there is too much fat in the blood (high triglycerides). Fortunately, these bumps will eventually go away after a couple weeks of controlling the amount of fat in the blood.

Lastly, Diabetic Dermopathy is a condition present on the feet and legs of diabetics. They look like discrete circular red bumps that may be flat or elevated. These lesions require no treatment , but will be present as long as a person is diabetic.

If you have similar changes happening on your skin, it would be wise to be evaluated by your primary care for diabetes. If diagnosed with diabetes, it is recommended to see a podiatrist every 2-3 months to avoid potentially limb threatening ulceration.

Diabetes Affects the Skin too

Diabetes is a disease that was once thought to be fairly benign.  Other than the effects it has on blood sugar and insulin, we thought it didn’t harm anything else.  We now know that diabetes adversely affects the kidneys, eyes, immune system, and blood vessels just to name a few.  Even the skin can be unfavorably affected.  Let’s discuss how diabetes can first show its ugly face through the skin.

The skin is often referred to as the window to the body because changes in it often are results from what is going on inside.  Just like every organ in our bodies, the skin needs oxygen to be maintained.   Oxygen is delivered to the skin via blood vessels that run just below the skin’s surface.  The oxygen diffuses through the vessel walls to get to where it is most needed.  However, with diabetes , the elevated blood sugar causes the vessel walls to thicken.  This not only happens to the blood vessels in the skin, but everywhere in the body.  This, at least in part, is why diabetics are at higher risk for heart attacks, strokes, kidney failure etc…

Without adequate oxygen, the overlying skin skin can atrophy (get thinner) or even die (skin necrosis).   These sores may heal, but then come back weeks later for no obvious reason.   Incredibly, in a small yet substantial number of cases, these changes to the skin may be the first indicator to someone that they are heading toward diabetes, or that they are at high risk for developing diabetes.   If you notice these skin changes soon enough, you may be able to start treatment by adjusting your eating habits and increasing exercise.  This may slow or completely reverse the progression of diabetes.

There are several different changes that occur in a diabetic’s skin.  Diabteic Dermopathy and Necrobiosis Lipoidica Diabeticorum are just two of the skin conditions we’ll discuss next post.

Tarsal Tunnel Treatments

Two posts ago we discussed tarsal tunnel syndrome.  As a reminder, tarsal tunnel is the same as carpel tunnel, except for that it occurs in the feet.  A nerve that provides sensation to the sole of your foot becomes compressed and trapped, causing discomfort and numbness.  Let’s discuss some of the options we have to treat this condition.

The treatment of choice is based on the cause of the pain.  Often, excessive pronation stretches the nerve to the point of causing tarsal tunnel symptoms.  In this case, controlling the pronation could potentially help.  This is done with custom orthotics made from molds of your feet taken at your podiatrist’s office.   The molds are then sent off to a lab that makes orthotics that are specifically made for your feet.  Once your feet get used to the inserts, the symptoms often disappear.

Tarsal tunnel can be caused by tendonitis (an inflamed tendon).  In a case of tendonitis, the extra fluid around the injured tendon may be compressing the nerve in the tunnel.  In this situation, the classic RICE (Rest, Ice, Compression, and Elevation) treatment may relieve symptoms.  This will allow the tendon to recover and repair.   In more severe cases, a small amount of corticosteroid can be injected into the area to decrease the inflammation.

If all conservative measures fail or are not indicated for your foot, surgery can be beneficial.  The surgical procedure involves releasing the thick band of tissue overlying the tarsal tunnel.  This relieves some of the pressure that is being put on the nerve.  Often in surgery, the surgeon discovers large varicose veins or some other benign space occupying lesion (ganglion cyst, lipoma etc) inside the tarsal tunnel that are small and hard to see on MRI or other medical imaging.  In these instances, the offending object is removed and surgery is very rewarding for the patient.

As mentioned before, treatment will differ depending on the cause.  Work with your doctor to decide which pathway of treatment is best for your situation.

Melanoma on the Foot

I’m sure you have heard about melanoma and its potential deadly effects. But did you know it can first appear under the toenail or the top of the foot. If unnoticed and left untreated, it can be just as fatal as melanoma found on the face or back. Let’s discuss the basics of melanoma, and then address its presentation on the foot.

Melanoma has a nice mnemonic (ABCDE) to help remind you and I how to recognize a cancerous mole before it advances too far.

“A” stands for asymmetry.

“B” stands for borders. If the borders are blurred, or not clearly defined, be suspicious.

“C” stands color. If the color of the mole is variegated, meaning different patches or streaks of irregular colors, suspect melanoma.

“D” stands for diameter. Most melanomas are at least 6mm wide, or about the size of the eraser on a pencil.

“E” stands for both elevated and evolving. You will always be able to both see and feel a melanoma because it will be elevated above the skin. Evolving means that a cancerous mole is always changing (i.e. getting bigger, changing color, becoming easier to feel). If a mole looks the same as it did 10 years ago, it probably isn’t melanoma.

Now that we know what to look for, it is important to remember that there are different types of melanoma. There is a type that seems to present more often on the palms of the hands and soles of the feet, including under the nails. How can you tell the difference between a blood blister under the nail and melanoma? A blood blister will grow out as the nail grows. If it is a melanoma, the discoloration stays in the same spot.

Your podiatrist can help you determine if a new discoloration under the toenails is something to worry about. He/she will be able to work with your primary care or dermatologist to treat the melanoma before if progresses.

Carpal Tunnel in the Feet

Almost everyone has heard of Carpal Tunnel Syndrome. With the advent and widespread use of the computer over the last 20 years, carpel tunnel has become more common than ever before. Carpal Tunnel Syndrome occurs when a nerve from the arm becomes compressed and irritated as it attempts to pass into the hand through a very small tunnel in the wrist. This causes numbness and discomfort in the hand, and if left untreated can cause permanent damage to the muscles in the hand.

Did you know there is a similar condition that exists in the feet? Similar to the hand, a nerve passes from the leg to the foot via a tunnel on the inside of the ankle. The contents of this tunnel include muscle tendons, a large artery, and veins. If anything within that tunnel becomes inflamed and enlarged (for example a varicose vein, or an inflamed tendon with extra fluid around it), the nerve within the tunnel will be entrapped and compressed. This condition is called Tarsal Tunnel Syndrome. Although there are many causes of this condition, the most common cause has to do with the mechanics of the way you walk.

Symptoms of this condition are very similar to that seen in the hand. The nerve compressed in tarsal tunnel gives sensation to the entire sole of the foot. Therefore, if Taral Tunnel Syndrome is present, you should feel a pins and needles, numbness, or shooting and burning sensations everywhere on the bottom of the foot. This pain may worsen with prolonged activity such as running or walking. In extreme situations, the pain may wake you up at night. If left untreated, the muscles in the foot may atrophy and cause hammertoes and other pressure points.

Tarsal tunnel can usually be treated by conservative measures, but without resolution, there are surgical options that exist to help decompress that area. We will discuss them in the next post.

Is Pronation Good or Bad?

Pronation is a word that I am sure you have heard at the podiatrist’s office and elsewhere in the foot and ankle world. You may even come across it when buying shoes or over the counter insoles. If you are an avid runner, you can find it used extensively in running magazines and other publications. Some say pronation is bad, or that you can “over pronate.” But what does it really mean?

An incredible amount of force is directed on your heel bone and foot joints while walking and running. Pronation is your body’s way of absorbing that force as you walk. There is a joint just below the ankle that moves in a way so that when you take a step, the foot is more mobile so it can adapt to the uneven surface that we are walking on. In podiatry, we say that your foot becomes a “loose bag of bones” or that it pronates. This allows the force to be shared equally across the foot and it spares our cartilage from being over stressed. In short, pronation is a good thing.

But just like anything else, too much of a good thing is bad. Once you have taken a step and your weight moves forward, you want to be able to push off that foot and propel yourself. At this point, you want your foot to be stiff and stable (or as we say in podiatry, in a supinated position). However, if your foot is still a “loose bag of bones,” meaning you pronate too much or for too long, you have nothing stable to push off of.

This is one reason why some people develop bunions, hammertoes, plantar fasciitis etc… You are pushing off of an unstable foot and the bones start to move in every direction, causing deformities. It would be similar to trying to hammer in a nail using a waffle. The waffle will twist and bend in every direction with nothing being accomplished.

The mechanics of feet are much more complex than the explanation I have given, but hopefully it will help you better understand how you walk.

Gout Treatments

During an acute gouty attack, the pain can be incredibly exquisite. Immediate treatment is needed to relieve the discomfort. Indomethacin is a stronger version of aspirin used to decrease the inflammation occurring in the big toe joint. This can be taken at the onset of pain and usually can decrease the pain within a couple hours. Once the pain has subsided, the drug should be discontinued due to its blood thinning effects.

Another drug that be taken on the onset of pain is colchicine. Colchicine, similar to indomethacin, will decrease the activity of the immune system within the joint, thus relieving the pain. Colchicine is most effective when it is taken within 24 hours of the onset of pain. Once the pain has subsided, colchicine (at a lower dose) can be taken to protect against gout attacks in the future. Colchicine is a strong drug that can cause nausea and vomiting, so it must be taken with caution.

While indomethacin and colchicine help with the pain, they do not address the root cause of the pain. Work with your rheumatologist to figure out if you are over producing uric acid, or not excreting enough of it. Additional treatments are available to address the origin of pain. Uloric is a newer drug that is showing promising results.

As mentioned before, consumption of foods like beer, steak, and other high protein diets can cause a spike in uric acid that can lead to gout. Avoiding these foods altogether, or minimizing the amount consumed at any given time can help to decrease uric acid levels.

If attacks become uncontrollable, there may be extensive damage to the cartilage in the joint and unrelenting pain. At this point, you may want to consider surgical options that would get rid of the pain permanently. A joint fusion is a procedure that you may consider to find relief. Discuss these options with your foot and ankle surgeon.