Surgery: Post op instruction

I am displaying the following post-operative instructions for the use of patients that I have operated on.  Depending on the type of surgery, and findings noted during the surgery, you may have been given special orders other than the ones listed on the page.  If that is the case, those orders would have been written on the instruction form in the area marked additional instructions.

As far as the post-operative medications are concerned, if you have a history of stomach or bleeding problems or allergies you may have been given medications other than the ones listed on this instruction page.

Finally, with regard to the section on when to call the office. It is very important to both the doctor and the patient that we keep in touch after the surgery.  If you have any questions about what you should be doing or if you are not sure about what to expect, please call the office.

BRUCE LASHLEY, D.P.M.

353 LEXINGTON AVENUE, SUITE 1501

NEW YORK, NY 10016

(212) 949-2901

www.footdoctornyc.com

POST-OPERATIVE INSTRUCTIONS

___Elevate your foot above the level of your heart as much as possible the first week

___Use ice around the ankle for about 15 minutes 4-6 times a day

___Rest in bed with the foot elevated the first two days

___After the second day minimal walking until your follow up visit

___Walk at all times with the post-op shoe or the Boot walker and use the cane

___Keep bandage clean and dry. Do not wet or change the bandage.

___Additional instruction___________________________________________________

________________________________________________________________________

MEDICATIONS:

___Ansaid—one tablet two times per day. This should be taken with food.

This medication is for mild pain and to help keep the swelling down.

___Tylenol with Codeine #3—one or two tablets every four to six hours as needed for

pain. This medication is for pain.

NEXT APPOINTMENT

Your follow-up appointment will be with Dr Lashley at his office on: M  T  W  TH  F

____/____/20____

CALL THE OFFICE IF:

• You have severe pain that is not controlled with the medication.

• You have blood soaking through the bandage.

• Your bandage gets wet.

• Your foot stays numb on the second day following the surgery.

• You have any questions regarding the surgery or the postoperative instructions.

Patient understands Sign here___________________________________________

BRUCE LASHLEY, D.P.M.________________________ DATE: ___/___/______

Amerigel instructions after nail surgery

GENERAL INFORMATION:

Stay off your feet as much as possible today. You may
wear any shoe, sandal or open toe footwear that does
not squeeze, constrict or put pressure on your toe(s).
Your toe(s) may remain numb for up to 6-10 hours after
the procedure. Please contact our office if you have any
questions or concerns.

Bleeding: Slight bleeding, discoloration and drainage
are normal.

Discomfort: You can elevate your foot to help
alleviate minor swelling, bleeding and discomfort.
You may also take Aspirin, Tylenol or other over-the counter
pain relievers as directed on the package. If
pain or discomfort is not controlled adequately, then
contact our office.

Removing the surgical bandage: Starting the
second day after surgery, carefully remove the dressing
and shower or bathe as normal. If the gauze or bandage
sticks to the area, dampen it with water or shower/bathe
with the bandage in place. This will make it easier to
remove with minimal or no discomfort.

DRESSING SHOULD BE CHANGED ONCE DAILY

FOLLOWING BATHING.

Instructions following
Nail Surgery using AMERIGEL®
WOUND DRESSING

Step 1: After showering or bathing, blot the
surgical site (nail bed) dry and apply a liberal
amount of AmeriGel Wound Dressing. Stinging
may occur and is normal.

Step 2: Cut a suitable size piece of gauze to fit
directly over the entire surgical area.

Step 3: Secure gauze in place with a band-aid.
IMPORTANT: The band-aid should be applied
around the toe resembling a ring. When dressing
a toe, apply band-aid loosely.

Why should I have a skin biopsy?

Why should I have a skin biopsy?

Skin cancer. How do you know if you have it? Ever wonder about that spot on your foot? Is it new? Has it changed? Does it bleed? Is it darker then it was in the past?

Growths (lesions) or discolorations of the skin occur all over the body, including the feet. So, it is not surprising when your podiatrist requests that you should have a biopsy to further determine the exact nature of the lesion on your foot. Often, more serious life-threatening skin conditions that appear on the feet are assumed to be warts, calluses or blisters. Unless these skin lesions are biopsied and sent to a skin pathologist for examination under a microscope, there is a good chance that the true diagnosis will be missed. The biopsy will determine the exact nature and true diagnosis of the skin problem, and will find if the lesion is malignant or benign.

There are several types of skin biopsies that can be performed by your podiatrist in the office. They are called: Punch, Shave and Excisional biopsies. The method performed depends on the location of the problem area and the type of skin lesion that is being investigated. Most of the time, the biopsy is done to remove a small portion of the skin in order to send a specimen to the lab for special staining and subsequent examination under the microscope.

Things to expect when you have a skin biopsy:

Most skin biopsies are performed in the office. After the injection of local anesthetic, the procedure itself should not be painful. Once the area is numbed by the anesthesia the skin is cleansed to avoid infection. Next, the doctor will use a surgical instrument to remove all or part of the skin lesion. A blade is used for Shave or Excisional biopsies and a cylindrical cookie-cutter type of instrument is used for the Punch biopsy. After the skin sample is taken, an anti-bleeding solution is applied. In rare occasions, one or two stitches may be needed to close the wound. The doctor then will apply a bandage over the wound.

The bandage is left in place until the next day when routine wound care can be started at home. There is very little post-procedure pain from these biopsies and patients may have to take Tylenol when the anesthesia wears off.

Now it is about two weeks since you had the biopsy and it is time to return to the doctor’s office for a wound check and, most importantly, find out the result of your biopsy. Most often, the final diagnosis from the biopsy taken in the office will take around seven to ten days to get back to the doctor. The doctor will go over your results from the report that he received from the lab and review the treatment for your condition. I suggest that all patients take a copy of the lab report for their personal records. Now you have your answer, hope the news was good.

Other reasons for having a biopsy:

Have you had redness and itching on your feet? Do you have coin size patches on your feet? Do you have skin lesions with small dark spots? Have you used over the counter fungal creams and not seen improvement? Do you have an area on your foot that is drier, scalier, thicker or darker than your normal skin?

• To determine the cause of the skin problem. Biopsy can let the doctor know if the skin problem is being caused by an infection, such as fungus, verses an inflammatory condition like dermatitis. Also referring to the case above, to determine if the condition is a cancerous verses a benign growth.
• To accurately form the best course of treatment for the skin condition. If the result of the test shows there are no fungal elements, then anti-fungal agents would be useless in treating this condition. Also, if the result shows that the skin problem is from a fungus, using anti-bacterial such as polysorin or anti-inflammatory agents like steroid creams would be useless The result of the study may also suggest that the entire lesion be removed because this condition may have a chance of turning into a cancerous condition in the future.
• Biopsies can determine if the hard strange skin on your foot is a callus or a plantar wart. Knowing this can help appropriately treat the condition.

The Case of the Elusive Glass Fragment

 

For the past 2 weeks, you have had a sharp pinpoint pain in your heel every time you take a step. You decide to see your podiatrist, who suggests that you take an X-ray to make sure there are no spurs, cyst or breaks in the bone. The X-ray is shown to you, and there are no sign of abnormality in the bone. Your podiatrist then suggests exploring the heel with diagnostic ultrasound.

An ultrasound may at first seem like an unusual imaging modality to diagnose the source of foot pain, especially since most people associate ultrasound imaging with pregnancy. Surprisingly, ultrasonography is a quick and inexpensive way to evaluate pathologies of the foot. In this case noted above, the ultrasound showed a concentrated bright spot in the heel with a tail of light waves behind the spot, which indicated a foreign body in the foot. Unlike ultrasounds, X-rays can only pick up signals from metal and bone, which have denser properties compared to glass and soft tissue structures.

Science of the Ultrasound:

Ultrasound uses high frequency sound waves that are emitted from a probe that is applied to the skin. The sound waves painlessly penetrate the skin and encounter bones, ligaments and tendons.  Each tissue type is made of different components, when the waves are reflected back to the probe they appear characteristic of that particular structure. The probe is attached to a computer that compiles the various sound waves and forms an image on a screen.  Tissues that contain more water such as muscle will absorb the ultrasound wave and will send little or no waves back to the probe. These tissues that absorb the waves will appear on the screen as dark areas.  Conversely bone, which contains less water, will reflect all of the waves back to the probe and therefore will appear on the screen as a white image. Using this gradient of  relative amounts of reflected waves and a firm knowledge of the normal anatomy a trained podiatrist will be able to determine the difference between normal and damaged or injured tissues in your foot.

Other Pathology Visualized by Ultrasound:

1. Ganglions

2. Neuromas

3. Foreign Bodies (like glass or metal)

4. Achilles Tendon Rupture

5. Tendon Abnormalities

6. Rupture of the Ankle Ligaments (Sprains)

7. Fascia tears and inflammation (Heel pain)

8. Bursitis

Advantages of Ultrasound:

1. Uses no radiation like X-rays or Cat Scans

2. Can perform live active or passive range of motion

3. Cost effective, especially compared to MRI

4. Conveniently used in an office setting

Healing yourself with Protein Rich Plasma

Platelet rich plasma (PRP) therapy is a cutting-edge non-surgical technique that is now available for use as an in-office procedure. Years ago, it was thought that platelets functioned solely to form blood clots — or, more specifically, to bind to each other at the sight of bleeding in order to form a “plug” to stop the flow of blood. Recent research has shown, however, that the platelet has a far greater role in the healing process than initially thought. When platelets aggregate at the sight of an injury, they not only form the plug to stem the bleeding but they also release growth factors. These growth factors, also known as cytokines, aid in the healing of injured tissues.

PRP Therapy: The Process

PRP therapy requires only a small amount of normal blood from the patient (approximately 20 cc’s). This blood sample is placed into a centrifuge in the office and is spun for approximately fifteen minutes. The final product is a highly concentrated platelet rich gel, which, when applied to injured tissue, accelerates the normal healing process.

On the day of the treatment, the patient is seated in the exam chair and blood is taken from his or her arm. Once the PRP gel is ready for implantation, the area being treated is injected with local anesthesia after which there is no further discomfort from the procedure.

To insure the accuracy of the placement of the platelet rich gel a diagnostic ultrasound is used. Then a needle attached to a syringe containing the gel is guided by the ultrasound into the areas of injury. After the procedure, a simple Band-Aid is applied. Because there is no surgical incision involved there is little or no post procedural pain.

The Science

When the PRP gel is applied to the area of injury, the platelets are activated to produce proteins capable of stimulating cellular growth, proliferation and cellular differentiation called growth factors. By concentrating the number of platelets found in normal blood by 10 times, the concentration of growth factors in the area is equally enhanced. This is significant in terms of the healing process because growth factors are responsible for attracting stem cells that will eventually become new tendon, bone or fascia.
The procedure is very safe. Since the blood is drawn and processed immediately in the same facility there is no chance of contamination or blood from another patient. Also since the injection consist of blood from the same patient begin treated there is no chance of allergy or drug reactions. Additionally, platelets have a natural antibiotic quality so there is very little chance of infection.

Use

In my practice, by far the most common ailment treated with PRP is the painful heel condition known as plantar fasciitis. However, I have also successfully treated tendonitis, partial tendon ruptures and inflammatory bone conditions.

PRP versus Cortisone Injections

When PRP is compared to cortisone injections for inflammatory conditions there are many striking differences. Cortisone injections result in immediate pain relief. PRP injections do not act as quickly. PRP procedures take longer to deliver results because the growth factors take time to grow the new tissue. However, the platelets release the growth factors that attract the stem cells and then produce repaired “new” tissue. The cortisone reduces the inflammation immediately but actually causes tissue weakening and damage. So the choice between cortisone and PRP comes down to fast relieve with potential tissue damage or actual new and repaired tissue that takes longer to relieve pain.
This new innovative and cutting-edge technique is just the beginning of the new branch of science known as “orthobiologics”. The day is fast approaching when medical science will be able to create new parts to cure the ailments and injuries that plague our bodies. “Protein Rich Plasma” is one of the modalities that are currently available to help the body accelerate the healing process and create new, repaired, healthy tissue.

PRP in the news:

The following articles on PRP are sited for your further reading on this subject:

http://articles.latimes.com/2008/oct/03/sports/sp-dodfyi3

http://www.nytimes.com/2009/02/17/sports/17blood.html?_r=1&emc=eta1

http://www.sportsgeezer.com/sportsgeezer/2009/02/simple-blood-treatment-helps-heal-most-sports-injuries.html

Heel Pain: What is it, What can you do?

Not a week passes by that while I am walking through the gym, I notice someone passing by who cannot put one of his or her heels on the floor. Some are women, some men, some thin and some heavy. As long as you walk, you are candidate for heel pain.

Every year, millions of Americans suffer from heel pain. By far, the majority of the cases of heel pain are caused by a condition known as plantar fasciitis (pronounced: fas-HEE-I-tis). This condition refers to the inflammation of the connective tissue that runs through the bottom of the foot from the heel bone to the front of the foot. This tissue is known as the plantar fascia. The fascia is most closely related to a tendon in appearance and texture, however, unlike a tendon there is no muscle attached to it. Due to the nature of this tissue, it is not very elastic and will get injured and begin to tear when exposed to excessive pressure. There are some factors that can make developing plantar fasciitis and heel pain more likely:

Aging. As we age, tissue breakdown becomes more prevalent. Accordingly, aging contributes to likelihood of damage to the plantar fascia.

• Poor shoe gear. Shoes that have little or no support tend to place greater strain on the fascia.
• Sports. Activity such as high impact aerobics, running and dancing can put a lot of pressure on the heel thereby causing pain.
• Poor biomechanics. Persons with high arches or flat feet are more prone to get heel pain. People with flat feet apply a greater stretching force on the fascia. When they walk, they have a greater tendency to damage the tissue by over-stretching. People with high arches have very tight fascia. This results in poor absorption of shock and allows the fascia to become injured from strain.
• Weight. There are many serious problems associated with being overweight. One of these problems is a strenuous challenge to the muscles, connective tissues and skeleton. In the heel, carrying extra weight makes the injuries that occur with poor biomechanics happen more often as well as more quickly. The excess weight also causes breakdown of the protective fat pad under the heel bone, which can result in direct injury to the heel bone and the fascia.
• Occupation. People who have to stand at work for long hours on hard surfaces are also subject to heel injury.

There are usually classic symptoms associated with plantar fasciitis. Here is a list of what you might feel if you have this condition:

• Sharp stabbing pain on the inside part of the bottom of the heel.
• The pain is usually worst first thing in the morning or upon getting up after sitting for an extended period of time.
• The pain may decrease after getting up, but the longer you are on your feet, the more the heel hurts.
• The pain may diminish during exercise, but will increase soon after.

If you have this kind of heel pain, you are not alone. As I mentioned before, millions of people suffer from heel pain every year. However, if the pain doesn’t go away in a few days don’t ignore it. Although, most cases of heel pain are plantar fasciitis there is a possibility that it could be something else and even something more serious. Some of the other conditions that cause heel pain are:

• A stress fracture of the heel bone.
• A bone cyst or tumor in the heel bone.
• A nerve entrapment behind the ankle, called Tarsal Tunnel syndrome.
• Certain types of arthritis.
• A partial or complete tear of the fascia.

Now that you know what it is, what can be a contributing cause, what it feels like and what else it might be, what can you do to help control the symptoms of plantar fasciitis?

• First and foremost, is stretching. By stretching the back of the lower leg, you will relieve the tension on the heel and subsequently relieve the stress on the plantar fascia. The most important stretches are the typical runners wall stretch. These exercises should be done throughout the day; one set per hour is ideal.  Watch my YouTube video to see the stretches demonstrated.  http://YouTube.com/watch?v=_sDrvbd-Ppc
• Night splints are devices that are worn to bed. They hold the foot and ankle in a position to prevent contracting of the muscle and tendon that you have been stretching all day.
• Ice massage done one or two times a day for about 10 minutes. This can be done while sitting in a chair and rolling your arch and heel on a small bottle of frozen water.

The next phase of therapy consist of oral or inject able anti-inflammatory drugs. A physical therapy regimen may be utilized to reduce the stress and strain on the fascia as well as reduce the internal swelling. At this time, custom orthotics can be fashioned to relieve the pain from plantar fasciitis. Orthotics and continued stretching are the best insurance against having a recurrence of the heel pain.

After these treatments more than 90% of patients with heel pain will have minimal or no symptoms. If you are suffering from heel pain, stretch, ice, wear good supportive shoes, diet and see your podiatrist for a complete evaluation.

What about the 10% of those who are not pain free?

See my next article on the treatment of resistant heel pain. In this article I will review PRP (Platelet Rich Plasma) injections, ESWT (Extracorporeal Shockwave Therapy), and surgery for heel pain.

Podiatrist: Get on your feet

As both a health care provider and a lifetime participant in a variety of fitness activities, I consider myself uniquely situated to be able comment on physical fitness and the lack thereof. As an avid exerciser, I am able to observe people in their role as exerciser, and as a podiatrist, I am able to see the result of poor training technique, over use and injury as a result of bad luck. On a daily basis, I listen to the stories of sports and fitness participants on all levels–those who have run a dozen marathons virtually unscathed, climbers who have scaled Mount Everest, would-be athletes, who, at forty, have just started yoga, pole dancing, or a walking program, and so on. From the avid life long sports participant to the middle-aged convert, all of these people have one thing in common–they are engaged in a healthy lifestyle. As I urged you in my last article, get off the couch and get moving.

Here is a list taken from the Center for disease Control’s web site outlining the benefits of regular exercise:

The Health Benefits of Physical Activity—Major Research Findings

• Regular physical activity reduces the risk of many adverse health outcomes.
• Some physical activity is better than none.
• For most health outcomes, additional benefits occur as the amount of physical activity increases through higher intensity, greater frequency, and/or longer duration.
• Most health benefits occur with at least 150 minutes a week of moderate-intensity physical activity, such as brisk walking. Additional benefits occur with more physical activity.
• Both aerobic (endurance) and muscle-strengthening (resistance) physical activity are beneficial.
• Health benefits occur for children and adolescents, young and middle-aged adults, older adults, and those in every studied racial and ethnic group.
• The health benefits of physical activity occur for people with disabilities.
• The benefits of physical activity far outweigh the possibility of adverse outcomes.

http://www.health.gov/paguidelines/guidelines/chapter2.aspx

The following story, taken from the annals of my daily contact with people, drives home an important point about accomplishing anything in life: if you are going to do something, do it correctly.

The American Diabetes Association recommends an annual visit to the podiatrist for all diabetics, even for those without risk factors. If patients have risk factors, the frequency of regular foot exams increases. Risk factors include absent pulses in the feet, loss of sensation in the feet or prior amputation of part of the foot. Yesterday, a diabetic male patient in his late fifties came in for his annual visit. The following is an account of our conversation:

I ask, “So how have your blood sugars been?” The patient responds, “not so good Doc.” Then I say, “Looks like you have gained some weight this year.” The patient responds, “Yes Doc, I gained about 10 pounds this year.” I then inquire, “Have you been getting any exercise?” The patient says with enthusiasm, “Oh yes Doc, I have been walking.” At this point, I now see some hope…at least he has started to participate in some cardiovascular activity. I respond: “that is great! Tell me about your walking program. How far are you walking? And how many days a week are you walking?” He then looks at me with some confusion and says, “No, I mean I am just walking, you know, from the train stop to my office and then, during the day, I walk in the office like to the copy machine or the men’s room.” I am not even sure what happened next, I think I was thrown into a state of consternation.

As a podiatrist, I can say that in normal walking you strike the ground with your heel and then load the front of your feet with 1.5 times your weight. This means that for every pound you gain, you are putting 1.5 pounds on these areas of the feet. This will result in trauma to the skin and the skeleton, as well as to the tendons in your foot and leg. Think about the other body components, the heart, the lungs, the blood circulation and burden of carrying additional weight.

Sometimes people exercise for menial goals, like to lose the newly noted love handle or tighten up that rear. But, you must realize that exercising is for your life. Please recognize, as I said in my prior article, that even if your motivation for doing the exercise is for your kids, your wife, your parents, it always comes down to the fact that it is for you—your life. In my last article I asked you to set a goal, now I am asking that, in addition, you follow through on that goal properly and appropriately–don’t kid yourself.

A 160-pound person running at 5 miles an hour will burn 307 calories, that same person will burn 38 calories reading for an hour. Reading, sewing, knitting even moving your foot on the gas pedal is to some degree exercising–but that is not sufficient. The United States Center for Disease Control recommends at least 30 minutes of exercise 5 or more days a week. Cardio exercise is not walking around the office, stretching is not bending to pick up the newspaper on your doormat; real results need real exercise. Read books or magazines about what you want to get involved in. Ask an expert if you have no clue. Ask your doctor, a trainer at the gym, a rock-climbing instructor, a ski pro, etc.

A study published in the New England Journal of Medicine in 2004 examined over 100,000 women and found that excess weight and lack of physical activity accounted for 31 percent of premature deaths. Another study conducted in Finland in 2004, which studied also nearly 16,000 men aged 30 to 59 over a 20-year period: Found that men who were engaged in a physically active lifestyle were 21% less likely to die of any cause during the course of the study. This increase in deaths was found to be primarily from heart attacks and strokes, but also from cancer. With this in mind, don’t you want to see your children or grandchildren a little longer? Don’t you want to experience quality life a little longer? I am sure the answer is YES. Get going, get started, it is time to move. Please, Don’t kid yourself.

Connecting Your Mind and Muscles

Yesterday at the gym.

Connecting Your Mind and Muscles

I have been a podiatrist for the past 27 years, I have been a health nut, exercise enthusiast and “gym rat” even longer. Over the years I have seen a variety of strange exercise techniques as well as even stranger cardio/exercise procedures and ever more outlandish locker room activities. Having spent five to six days a week training in the gym all these years, there are plenty of yesterdays in the gym. Being a healthcare provider treating the foot and ankle for nearly three decades there are plenty of times I get to see the resulting insult and injury for some of those behaviors I have observed at the gym the day before.

However, not all is lost to my observations of those aberrant quirks that result in detrimental outcomes. I have also seen a lot of excellent technique and beneficial behaviors and have incorporated these to make my workouts and I dare say, my life, better. Let’s face the facts——-exercise and keeping yourself in shape is far more advantageous to one’s overall well being then the few temporary set backs to the skeleton or skin that all athletes suffer from time to time. Even with decades of experience, I still subscribe to the “injury of the month club”. However, over time I strive to correct, improve and attempt to perfect my exercises, my treatment of patients and my life. I would say that much of this improvement I owe to that microcosm I choose to spend so much time in “the gym”.

The United States Department of Health and Human Services recommends 60 minutes of exercise daily just to maintain your current weight.

For the purposes of this article my message is not, see you at the gym tomorrow, however the message for today is get started improving your life. Not all exercise is done in the gym. I am not suggesting that my type of exercise is what everyone should do, nor is it the only way to stay in shape. Millions of years of evolution did not produce our arms and legs, heart and lungs to sit at our desk all day and our couches all night. Dependant on you age current health and what you enjoy, raking leaves, taking a brisk walk, playing volleyball or basketball. It is time to start using your body for more than using the Gluteus muscle as a cushion.

Why should you start exercising? Possibly, for others–your children, teammates, co-workers. Don’t let them down. Definitely, for yourself. You may feel better with an improved self-image, more energy, or having powers and abilities far beyond the average couch potato. You can’t let yourself down.

How do you start? From many conversations at the gym the reason most people tell me they are staying in shape is to avoid the relative poor health of generations gone before. Interestingly, that same theme is repeated in my office when I hear, “well I know it is not bad now, but I don’t want to wind up like Grandma Mary.” So maybe you don’t want that early heart attack, the hip replacement or type 2 diabetes. Think about how painful and depressing developing one or all of these ailments would be. Develop the mindset that each and every time you are exercising in some way, you are literally pushing back that illness. Of course I am not ignorant, not everyone will succeed at staving off the family genetic predisposition to illness. However, not everyone goes into marriage anticipating a divorce.

Set a goal. This is important for your exercising, as well, as all the other aspects of your life. Some of the motivational experts will tell you that you have to write it down and keep looking at it. I think they are correct. However, I believe that once you write it and look at it and you can then throw it out. (The paper that is) This is because once your hand has written it, then it is true and therefore you have to follow through. Maybe you want to get below 200 pounds or maybe ever 300 pounds. Maybe you want to run a marathon or just walk around the block in less than 15 minutes. Maybe you want to bench press 315, 225 or just the bar. Maybe you want to dance all night without waking up the next day with your legs killing you. Or maybe you’re like me and want to think that you will still be doing a half hour of cardio, a half hour of weight training and abs and stretching when I am 95.

It is now time to get off the couch and move. Whatever goal you have set, when you reach it you will feel great. As a matter of fact, once you reach your first goal you will feel so good you should have no problem setting your next objective. It is your mind, your body, and your life_________make the most of it all the time.