Turf Toe

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

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

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

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

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

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

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

Think R.O.D.

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

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

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

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

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

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

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

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

Decreasing You Risk of Ulceration

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

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

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

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

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

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

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

Circulation in the Diabetic Patient

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

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

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

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

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

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

A Few Reminders About Diabetes

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

How Many Legs Does a Spider Have?

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

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

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

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

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