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.