The ABC’s of Skin Care

As the winter snow melts away and the sun begins to shine we can rest assure that spring is headed our way and shortly behind it, summer! That’s the time of the year when we hit the beaches, kick up our outside workout routines and picnic at local state parks hoping to catch some rays. As you pack your lunches, fill your water bottle and throw your bathing suits on, don’t forget the sunscreen!!

Sunscreen should be worn daily on your hands and face, even in the winter months, as those areas are always exposed to the sun. However, as we peel off layers of clothing with increasing spring and summer temperatures, it’s important to apply sunscreen to any exposed area of skin and ensure that our kids and loved ones are also slathering up. Exposure to the suns rays without skin protection is the largest risk for the development of skin cancers.

In addition to protecting our skin and decreasing the risk of associated skin problems, we need to remember to check our skin for new freckles and areas of changing color/pigmentation. If you check your skin daily or at least weekly, you can catch areas of changing pigmentation and new freckles that might be concerning before they become a real problem.

The ABC’s of Skin Care are listed below and provide a guideline for those daily/weekly skin checks. If any areas or your skin exhibits signs of A, B, C, D or E it should raise your index of suspicion and prompt you to follow up with a Dermatologist, or Podiatrist if these are areas on your feet.

A – Asymmetry: The lesion is asymmetric if you bisect it and the two halves are not symmetrical.

B – Border: Any border that is raised, scalloped or blurry may be abnormal.

C – Color: If the lesion is more than one shade or several different colors, or if the coloration of the lesion has changed, take notice.

D – Diameter: Any lesions larger than 6mm (the size of a pencil eraser) or a lesion that is growing in size, should raise cause for concern.

E – Elevation: Any lesion that is raised off the surface of the skin is considered elevated, and is worth having your Dermatologist or Podiatrist take a look.

Noticing any of these changes early-on significantly improves your long term outcome should any of the lesions turn out to be skin cancer, and if they turn out not to be skin cancers, you can sleep easy at night knowing that.

Just as a reminder, here are some things you can do to help decrease your risks:

Always apply sunscreen before leaving the house, especially to your face and hands, as they are always exposed to the sun.

NEVER tan in a tanning booth.

Check your skin daily, or at least weekly, using the ABC’s as a gauge of changing freckles or new areas of interest.

Schedule your yearly Dermatologist check-up. They can assure you aren’t missing any skin changes putting your mind at ease.

If you notice any areas of new or changing discolorations on your feet or around your toenails, especially changes that are darkly pigmented, see your Podiatrist for evaluation.


Next week we’ll tackle some of the specific cancers that can be seen on the lower extremities. This information is not intended to scare you or to induce paranoia, but rather to inform you so that you can decrease your risks and live a long, healthy life!

Fitness ‘Kicks’

Over the past few years more and more shoe companies have been branding and advertising ‘workout’ sneakers that promise to tone your buttocks and thighs by simply wearing the sneakers during normal daily activities. Consumers have responded favorably to such advertising gimmicks and on any given Saturday at the grocery store, a handful of shoppers can be spotted sporting these rocker-bottom ‘kicks.’

So, how good or bad are these revolutionary toning sneakers for you? Well, the jury may still be out on some of the claims by these shoe companies, but we do know that the have caused some problems in the lower extremities! Below are a few of the claims that shoe companies are using to reel in consumers, followed by some of the problems Podiatrist are seeing in response to such purchases.

The Claim: The sneakers, by design, create an unstable center of gravity that stimulates the muscles in your lower extremity to work harder in order for you to maintain balance.

The Science: Creating an unstable center of gravity does induce the muscles of the legs and core to work harder to overcome that imbalance. Try standing on one leg. When you try to stand on one leg, it takes a few seconds for you to find your balance and you can feel yourself teetering back and forth to maintain an upright position. The leg that remains on the ground has all the muscles in it working hard to keep you standing. This claim and the science behind it make perfect sense.

The Problem: Some patients may not have the muscular strength or the appropriate level of balance for their body to accommodate to the unstable center of gravity that the sneakers induce. Therefore, rather than increasing their muscle strength and stability, they are suffering from injuries such as lateral (outside) ankle sprains and falls! Ankle sprains, depending on the severity, can be very debilitating injuries and especially in older patients, recovery is not always optimum.

The Claim: Walking in these sneakers is like walking on sand. The central portion of the sneaker elevates your foot off the ground and therefore, allows your heel to sink below ground level during normal walking. This forces the muscles in your legs to work harder to overcome that resistance in order to propel you forward for proper gait.

The Science: Picture a stability exercise ball that so many people at the gym use for doing sit-ups. By balancing on the ball alone they are working their core muscles and when leaning backwards, their back, shoulder and head fall below the level of the ball. They are in what is called a “negative position,” which increases the resistance and stability needed to complete a forward sit-up. This increases the workout factor on the body’s core muscles and yields greater results. This same technology is inherent to rocker-bottom workout sneakers. By falling into a negative position where the heel sinks below the level of the foot, the muscles in the legs must work harder to overcome that resistance. This claim makes perfect sense.

The Problem: By placing your foot in a negative position as the heel sinks backwards, stress is placed on the muscles in the back of the leg as they lengthen to accommodate the change. For patients that have tight posterior leg muscles (mainly the achilles tendon made up of the gastrocnemius and soleus muscles), the negative position can create problems! Patients are coming into the Podiatrist office complaining of posterior heel pain and are being diagnosed with achilles tendonitis (inflammation of the sheath surrounding the tendon), calcifications of the tendon (reactive boney growth within the tendon secondary to excessive stress) and retrocalcaneal bursitis (inflammation of the bursa or cushiony sack between the achilles tendon and the bone). None of these diagnoses sound like much fun, and I can assure you they are not! Often patients have significant pain and if not treated in the early stages, patients can suffer an achilles tendon rupture; a very difficult injury to overcome.

Next time you see a commercial advertising rocker-bottom workout sneakers, you’ll be a little more informed about the potential lower extremity problems they can create. If you chose to make a purchase, just use caution. If you start to suffer aches and pains in your feet or legs, discontinues wearing the shoes and see your Podiatrist for evaluation. Happy Walking!

Interesting but Benign!

Many people know what a cyst is, but often times the word “cyst” can ignite fright in people, as it has developed a negative connotation to it over the years. However, when the word ganglion is used as its predecessor, the negative connotation has permission to be dropped. Ganglionic cysts are benign (non-harmful) fluid filled masses or bumps, solely involving the soft tissue that can develop on any area of the body, but of course as Podiatrists, we see them on the lower extremities!

So first, where do these ganglions come from? Well, their exact cause it unknown, but in the lower extremity they usually appear on the dorsal (top) surface of the foot, also known as the extensor surface of the foot. They are typically attached to an extensor tendon, meaning a tendon that travels across the dorsal surface of the foot, and therefore, it has been speculated that ganglions form secondary to pressure along such tendons from shoe gear, prompting the body to protect itself via creation of a ganglion.

In addition to being closely affiliated with an extensor tendon, ganglions typically form near a joint in the foot, which isn’t too difficult as the foot is filled with numerous bones and thus numerous joints. They use the joint as a place to tether themselves to (via a stalk), often making definitive removal more difficult.

For the patient, treatment isn’t sought until one of two things occurs: the ganglion becomes painful and starts to limit activity or shoe wear, or the ganglion becomes so large that patients begin to get worried about what lies beneath! Either way, when presenting to a Podiatrist, you will be evaluated in the same manner, and a diagnoses of Ganglionic Cyst will be made. Podiatrist have several ways to come to such a diagnoses including palpation of the cyst as a freely moveable mass in the first layer of tissue below the skin (subcutaneous) in addition to its location over an extensor tendon. X-rays will most likely be taken to ensure that there is no bone involvement, which with Ganglionic cysts, there typically isn’t bone involved: it’s strictly a soft tissue mass. Finally, if your Podiatrist feels as though it is necessary, you will be sent for an MRI, which can look specifically at soft tissue and determine the exact location of the mass, its attachment to surrounding structures and its overall size.

At this point, depending on the Podiatrist’s treatment choice for ganglions, they may suggest one of three treatment options:

Do nothing. If the ganglion is not painful and is not hindering daily activity it can be left alone. Sometimes they will increase in size to where they will become painful, at which time the Podiatrist will tell you to return for options 2 or 3.

Aspirate. This means that the area will be injected with a small amount of numbing medication, punctured with a sterile needle and the fluid inside, typically gelatinous and pink in color, will be “squeezed” out, flattening the cyst and providing immediate relief. After the fluid has been aspirated a small amount of cortisone will be injected into the area to decrease inflammation and prolong recurrence. However, recurrence is highly likely and in some patients the cyst will return within months, while in other patients it will not return until years later, but non-the-less, in the same location.

Surgical excision. The ganglion can be surgically excised, helping to decrease its risk of occurrence. The procedure is technically easy and requires numbing medication around the site of the ganglion, a small incision over the site and removal of as much of the ganglion as can be teased away from the extensor tendon as well as removal of the stalk. This option provides the least rate of recurrence of the ganglion, but for unknown reasons, it may still return!

Ganglions are interesting soft tissue masses, that are benign and may or may not require treatment. However, it is always best to seek the opinion of your Podiatrist rather than self-diagnose. They can provide several options that may help eliminate or relieve any symptoms you may be experiencing secondary to your ganglion, and knowing what that ‘random bump’ on your foot is, will at least put your mind at ease!

Check Out Those Nails!

A question that I encounter from patients on a near daily basis is: can you really tell the status of a person’s overall health by looking at their nails? The answer, although it seems strange, is yes, to some extent a Podiatrist can understand a lot about a patients overall health just by looking at their toenails and fingernails.

It seems a little bit crazy! How can you possibly know if a patient has liver disease, kidney disease or lung disease just by looking at their nails? Well, for whatever reason, the body communicates its overall health in various ways and one of those ways is through patterns, lines and color changes in the nails.

My hope is that this week you will gain a greater appreciation for the look of a person’s nails, while understanding that the appearance may suggest an underlying disease, but is by no means an absolute. Some people’s nails are just “naturally” discolored, ridged etc. Therefore, it might not be the greatest idea to play ‘Doctor’ and inform innocent bystanders of an illness you think they might have, since you’ll be an ‘expert’ in the category of nail appearance after this week!

Here are a few of the disease conditions that manifest themselves through changes in the appearance of toe- and finger-nails.

Psoriasis:

Psoriasis is an inflammatory disorder that typically manifests on the skin, but as it progresses can lead to Psoriatic Arthritis in many patients. One of the most distinct presentations, which we blogged about in our article on Psoriasis, is nail pitting (small indentations in the nail that are white in color). When found in association with loosening of the edges of the nails (onycholysis) and a yellow-brown discoloration, psoriasis is a likely diagnosis.

Liver Disease (Cirrhosis):

The manifestation of liver disease in the nails most typically comes in the form of what the medical field call’s Terry’s Nails. This nail presentation demonstrates a pink (normal) coloration on the most distal part of the nail, meaning the furthest area from the foot/hand, while the portion more proximal or closer to the foot/hand is completely white in color.

Dehydration:

Splitting of the nails at their very ends signifies dehydration of the nail plate. Drink more water!!

Heart/Lung Disease:

Clubbing involves both the nails and the actual toes and fingers (digits) in its appearance: a generalized enlargement of the digits with curving of the nail. The nail thins out and curves itself in order to remain approximated with the digits as they enlarge. Again, clubbing not exclusive to either heart or lung disease but may suggest such an underlying disorder.

Arsenic Poisoning:

To the CSI and Law and Order Fans out there, this one is for you! Arsenic poisoning in a patient presents as very distinct Mee’s Lines. These are lines across the nail from one side to the other that are white in color and may be single or double in presentation. The next time you’re watching your most favorite episode of a Forensic Science show when they recognize Arsenic poisoning as the cause of death, listen for clues they found in relation to the patient’s nails!!

Peripheral Vascular Disease (PVD):

We had previously blogged about PVD and how it designates a change/alteration in blood flow to the extremities, especially the legs. Changes in blood flow result in a decrease in nutrients and infection fighting cells to the places furthest from the heart, meaning fingers and toes. Therefore, this patient population is more likely to suffer from onychomycosis, which is a fungal infection in the nails, presenting as thickening, deformation and yellow color changes.

Keep in mind that any nail presentation is not an exclusive diagnosis for an underlying disease condition, but it does signal to us as Podiatrist that we need to investigate your over-all health just little bit more. It may prompt us to ask more questions in our history taking to determine if you have any underlying disorders or it may prompt us, as in the case “PVD nails” to have additional non-invasive studies completed to determine how well the blood is flowing to your extremities.

Now that you’re a nail expert go out and observe the public, just be sure not to worry any innocent bystanders with your “diagnosis!”

What’s Your New Years Resolution?

Many of us start the beginning of each New Year with a resolution. Whether it be a resolution to lose 20 pounds this year, do something good for others, develop a healthier lifestyle, pay off debt or quit smoking we set out on the road to success and by mid-February, we are floundering! This year, I want to hold you to those resolutions, especially the one you made to run that 5k, 10k or half-marathon.

This weeks tips are aimed to help keep your running legs hot, propelling you through the winter season toward achieving your goal!

1. Make sure to always warm up and cool down.

With any exercise routine, and especially while training for that race you’ve resolved to complete, warm up and cool down sessions are a must! The warm up allows your muscles to prepare themselves for the workout ahead, decreasing your risk of injury such as muscle strains and sprains. Try 10 minutes of walking or light elliptical training and a stretching session. It is especially important to stretch the muscles in your legs, including hamstrings, quadriceps and calf muscles, as those muscles will receive the highest demand over any other muscles in the body while running. Cooling down is also important, with 5-10 minutes of walking and a full-body stretching routine. This helps prevent build-up of lactic acid in the muscles decreasing the amount of “muscle pain” you will experience the following day.

2. Invest in a good pair of supportive running shoes.

Think about it: you run on your feet, your feet are supported by shoes, and those shoes transmit your body’s weight through to the ground. Do you really want all that force traveling through a worn-out pair of running shoes that could significantly increase your risk of foot and ankle injury? When you head to the shoe store, make sure to bring with you a pair of socks that you would normally run in. Also, if you have orthotic devices that you wear, bring those to try on with your potential new running shoes. Have your feet measured for accurate size and don’t be afraid to run around the store in shoes you are considering buying.

For more buying tips, check out the American Podiatric Medical Associations (APMA) website: http://www.apma.org/MainMenu/Foot-Health/Foot-Health-Brochures-category/Learn-About-Your-Feet/Footwear.aspx

3. Start off slowly.

It’s important that at the beginning of any exercise routine or new running workout, you advance your distance, pace and level of resistance slowly. If you advance too quickly with your body not apt to handle such an increase in activity level, your risk of injury skyrockets! Things like muscle strains, stress fractures and plantar fasciitis become real threats. Take it slow, gradually increase your pace and your distance over the weeks leading up to your race, and abide by tip #4: Enjoy rest days off.

4. Enjoy rest days off.

Taking rest days from your training routine, at least one day per week (two if possible) is very important for reducing your risk of injury and overloading your body. Your body needs days to recover from intense workouts and you feet need a break too!

Before starting any exercises or training routine it’s important to be evaluated by a physician to make sure you are in good physical health and able to handle the demands that will be placed on your body. In addition, you should be evaluated by your Podiatrist who can identify areas in your lower extremities that might lead to injury, while providing solutions to prevent such injuries. They can also suggest warm-up and cool-down exercises specific to the lower extremity that can be included in your routine. The APMA also suggests some lower extremity stretches. Check them out at: http://www.apma.org/MainMenu/Foot-Health/Foot-Health-Brochures-category/Sports-Medicine/Running-and-.aspx

Hit the trails while following these simple tips and you’ll be well on your way to accomplishing that New Years resolution to complete your 5k, 10k or half-marathon this year. See you on the road!

Why Does it Take So Long for My Fracture to Heal?

When patients are diagnosed with a fracture, the first question they have after the initial, “Do I have to have surgery” is: How long will it take to heal? The answer obviously depends on the location and severity of the fracture, but no matter the answer, the patient always expresses shock. They can’t possible fathom why it is going to take X-number of weeks for their fracture to heal. I’ll let you in on a little secret – there are a lot of factors that go into bone healing and the number of factors that play a part increases as the compliance of the patient decreases!

This week I hope to help you gain a general understanding of what the body must accomplish in order for bone to heal, in addition to some things you can do that might help along the healing process. We will evaluate bone healing from the approach that you have suffered a fracture that is not significantly displaced and does not require surgery, but that will require casting and non-weight bearing on the affected leg, with crutches for proper healing.

In school they teach physicians that specific cells called osteoblasts, osteoclasts and osteoid matrix are required for adequate bone healing. The names of these cells are unimportant but their presence at a fracture site is required for healing, allowing the body to form new and sturdy bone. In an optimal healing environment (which is what we are assuming), the cells are permitted to cross the fracture site, reaching the other side and filling the defect with new bone.

With that said, those cells move across the fracture site and lead to healing in a series of specific steps: the phases of bone healing.

Phase 1: Inflammatory – in this phase, the area between fracture fragments must fill with blood cells and macrophages (think Pac-Man) that remove broken bone from the area, setting the stage for bone forming cells to invade. This usually takes place during the first 3 days after fracture has been suffered, assuming immediate medial attention and casting has been achieved.

Phase 2: Reparative – in this phase, the cells that we discussed above will invade the area producing and reforming bone needed to fill in the defect. They deposit all the necessary components of healthy bone setting the stage for the 3^rd phase of bone healing. This phase lasts to about day 21 post-injury.

Phase 3: Remodeling – in this phase, all those cells and components of healthy bone that were deposited during the reparative phase are left to arrange themselves in the direction of healthy bone, matching that of the surrounding un-fractured bone. Blood supply is fully restored throughout the area of fracture and the bone will strengthen in response to forces applied to it. Therefore, sometime late in this phase of bone healing your cast will be removed and you will be permitted to place some weight on the affected leg, allowing the body to detect normal weight-bearing forces, strengthening and remodeling your bone in response to them. This process can last 6-8 weeks from the time the fracture was suffered and even longer if optimal conditions are not achieved.

When suboptimal conditions are present, where the patient is not immediately immobilized, does not remain non-weight bearing on the affected leg and fails to follow their Podiatrists instructions, these phases become skewed. What can happen is that motion at the site of initial fracture induces additional phases of bone healing that inevitably elongate the healing process.

So what can you do to help the bone healing process stay on course and prohibit those additional phases from coming into play with a longer healing time than is necessary?

1. Follow your Podiatrist’s instructions. Whether that be staying off your foot and using crutches for assistance or elevating your foot as much as possible, follow their instructions. Contrary to popular belief, we do know what we are talking about and we aren’t giving you any of those instructions for our own health, but rather, for yours!
2. Stop Smoking. It has been shown that smoking inhibits the natural course of bone and wound healing. Even cessation of smoking the day you suffer that fracture has been shown to make a difference. You don’t want to give your body any reason to slow down the process of healing because you need one more cigarette.
3. Eat healthy. Eating healthy affects levels in your blood called pre-albumin and albumin which, when you are consuming proper nutrition those levels reside around their normal values. Should they drop below normal, indicating poor nutrition, healing of bones and soft tissues becomes inhibited. Eating a balanced diet also provides your body with the calcium it requires to help build strong and healthy bone. Calcium is a major component in bone.

Understanding the healing process and following these simple guidelines can ease your fears about a long recovery and your fracture will be healed before you know it!

Don’t Get ‘Bitten’ by the Frost!

With Mother Nature’s most recent gift of ice and snow, it seems fitting that we talk about a cold related emergency: frostbite! Historically, frostbite was known to be a problem suffered only by military personal and hunters, who spent hours in sub-freezing temperatures due to the nature of their profession; however times have changed and civilians are now included in those at risk.

Frostbite occurs when tissues freeze after being exposed to temperatures below the skins ‘freezing mark,’ which is 2 degrees Celsius. Those individuals most susceptible still include military personal and hunters, but also include those of us who spend large amounts of time outdoors; whether that be all-terrain hikers, sanitation workers or recreational skiers. Other individuals most susceptible include those who are dehydrated, malnourished, intoxicated or elderly. Parts of the body that are most affected include areas that protrude from the body, meaning ones fingers, toes, ears, nose and cheeks!

There are two mechanisms by which tissues can freeze resulting in frostbite:

1. Directly: As the tissues are exposed to colder and colder temperatures ice crystals form within the tissues causing the surrounding cells to lose some of their water content (dehydrate). The state of dehydration leads to breakdown of the cell structure and results in frostbite.

1. Indirectly: Known as the “hunter’s frostbite,” this mechanism occurs when there is increased blood flow to the freezing tissues followed by decreased blood flow, and increased blood flow again. The alternating blood flow leads to inflammation and damage to the small vessels within the affected tissue, which in its most advance stages leads to inability for blood to reach those sites indefinitely, i.e. frostbite!

Whichever mechanism of ‘freeze’ causes the frostbite, symptoms typically present in the same fashion. Initially burning, numbness, tingling and/or itchiness in the affected area occurs, warning of impending freeze. When these sensations are experienced it’s best to get inside and warm up for a bit before heading back out into the cold temperatures. However, if you don’t notice these symptoms, or fail to heed their warning, progression of your ‘tissue freeze’ will continue. The affected areas will begin to turn white, there will be an absence of sensation and swelling will occur. In severe cases, blistering of the affected area occurs with purplish/blue color changes and hardening of the tissue or a “wooden” feeling to the skin. It is at this end-point that the danger of losing the affected part becomes reality.

Classically, four stages of frostbite have been described from 1^st degree being the most benign and resulting in no permanent injury or tissue damage to 4^th degree frostbite being the most harmful with complete tissue death and loss of the affected part. There are also categories of frostbite such as Chilblain’s and Frostnip that don’t fall into one of the four stages, and are characterized as milder forms of the typical frostbite. In any situation, if you are even the tiniest bit suspicious of frostbite, it is important to seek medical attention immediately. Treatment, including controlled/monitored rapid re-warming of the affected area will help save as much tissue as possible.

Frostbite is not an injury you want to suffer from so prevention is key, but if you find yourself in a situation where frostbite seems probably remove yourself from the cold temperatures immediately and seek medical attention for evaluation and appropriate treatment.

Protect those areas most at risk by bundling up with gloves or mittens, hats, earmuffs, wool socks and water proof shoes next time you head out to shovel your sidewalk or make snow angels in some fresh powder!