Posts Tagged ‘Health’

Chronic Tendinopathy of the Achilles tendon and Plantar Fascia

December 13, 2015


Pain on the back or bottom of the heel caused by a condition known as tendinopathy is a common problem among people who are trying to lead an active lifestyle. The Achilles tendon and the plantar fascia are tendon type tissues that each play a key role in maintaining balance while walking and standing and are commonly afflicted with this condition. The pain in these areas often emerges from overuse following repetitive strain or after a recent increase in activity. Most people who have heel pain from tendinopathy will experience relief with the use of stretching, supportive shoes, anti-inflammatory therapy and shoe inserts. However, if the condition is not addressed, the acute inflammatory process continues as the body attempts to repair the damaged tendon. Eventually, this healing process ceases as the tendon becomes riddled with scar tissue.

Chronic tendinopathy in these areas can severely impair your ability to function in your daily life. Often described as tendinosis or fasciosis, this recalcitrant condition may persist for more than 6 months and is not relieved with the use of anti-inflammatory medicine or corticosteroid injection. This chronic, degenerative process manifests as thickened fibrous tissue within the tendon or fascia. Blood flow decreases to the diseased area and the normal healing process is halted. If conservative options fail to alleviate the symptoms of chronic tendinopathy, novel therapy that involves restarting the healing process should be the next option considered. Since healing is a normal response to injury, restarting the healing process in chronic tendinopathy could involve either introducing a controlled injury to the fibrotic/scarred tissue or directly implanting the necessary growth factors. There are several therapies currently available for treating pain due to chronic tendinopathy.

New Approaches to Treating Chronic Tendinopathy

 TENEX FAST – Focused Aspiration of Scar Tissue

The TENEX FAST system provides a novel way of directly accessing the diseased portion of tendon, using ultrasonic energy to break the fibrous tissue within the Achilles tendon or plantar fascia. This minimally invasive approach uses a handheld device with a micro tip. Using ultrasound imaging as a guide, the handheld micro tip is brought to the area of injury through a small incision in the skin. With the use of a foot pedal, ultrasonic energy is emitted through the micro tip to emulsify the scarred portions of tendon. The micro tip is also equipped with a saline delivery system to flush and aspirate/remove the debrided fibrous tissue. This process has been termed phacoemulsification and essentially cleans the scar tissue in a focused manner, leaving behind healthy tendon. (1) Prior to the procedure, local anesthetic is injected near the affected area to control pain during the procedure.

For procedures involving the plantar fascia, one can bear weight on the affected limb with a CAM boot and cane for assistance for 2 weeks. For Achilles, a CAM boot and crutches for guarded weight bearing is used. After the procedure, the doctor will determine when transition out of the CAM boot to supportive shoe gear and careful return to normal activities is appropriate. Any discomfort experienced following the procedure can be controlled with pain medication as prescribed by the doctor.

Platelet-Rich Plasma Injection

Platelet Rich Plasma, or PRP, is an orthobiologic substance that is used to alleviate pain caused by chronic tendinopathy. As mentioned previously, the diseased portion of the tendon has decreased blood flow and is unable to heal. PRP functions by directly stimulating the healing process in this area through the use of growth factors and inflammatory molecules from the patient’s own body. Prior to the procedure, blood is drawn from the patient. It is then spun in a centrifuge to separate the platelet-rich plasma from the rest of the blood. (Because a centrifuge or spinning machine is used in this procedure, PRP is sometime commonly known as, “Blood Spinning”) The platelet rich plasma is then drawn out of the processed vial and injected into the affected area. This procedure has now directly implanted growth factors into the site of injury. These growth factors help recruit other cells from the body which are involved in healing of the injured soft tissue.

During the procedure, ultrasound imaging is used to visually inspect the tendon or fascia and find the specific region of injury. Once the area of injury is located local anesthetic is used to numb the area of interest and the PRP is injected. In order to stimulate the process of healing, many small injections will be peppered into the diseased tissue to introduce a form of micro trauma and encourage the body to recruit inflammatory cells. Doing this essentially restarts the healing process in the previously scarred tendon. Following the injection, anti-inflammatory medications and icing should be avoided in order to allow the inflammatory healing process to work. A short leg-walking CAM boot is worn following the injection. Avoid walking without the boot on the affected limb for 2 week. After 2 weeks, patient can transition to supportive shoe gear.

Amniovo – Amniotic Membrane Injection

Amniovo is a form of dehydrated human amniotic membrane and is another way to introduce growth factors to the site of injury in chronic tendinopathy. Although amniotic membrane tissue is known to possess healing potential, there would be risks involved with direct implantation of untreated, fresh amniotic membrane. In order to avert these risks, the amniotic membrane used in this process is taken from screened and tested donors, it is then purified using the PURION process. This purification process allows for the dehydrated amniotic membrane to be safely implanted to the affected site without the risk of disease transmission and allows for the graft to be stored for up to 5 years. Once purified, the product is in powder form and is suspended in saline solution to use as an injection. Through the direct implantation of growth factors, injection with Amniovo helps the tendon’s diseased tissue heal. In fact, in a study using dehydrated amniotic membrane injection compared to a control injection of local anesthetic and saline the amniotic membrane injection was shown to be more effective at relieving pain from chronic plantar fasciosis. (2)

Once again, ultrasound-imaging guidance is used to identify the diseased portion of tendon or fascia. An anesthetic injection is first used to numb the affected area and Amniovo is then injected.

Following the injection, a walking boot is used for 2 weeks in order to protect the involved site. Two weeks after the injection the patient can transition to supportive shoe gear.

In Conclusion

Chronic tendinopathy is an issue that plagues many people who are attempting to engage in an active lifestyle. Because the condition may not respond to anti-inflammatory therapies, many patients are frustrated, especially if they would like to avoid surgery. Novel therapies that combat this chronic, degenerative process have emerged that help restart the healing process in the diseased tissue. If you have had heel pain from chronic tendinopathy that has stopped you from leading the daily lifestyle you would like to, speak with your doctor to see which therapeutic option would best suit your needs and help you get back on your feet.


1) Barnes, D. Ultransonic Energy in Tendon Treatment. Operative Techniques in Orthopaedics. 2013

2) Zelen, C; Poka, A; Andrews, J. Prospective, Randomized, Blinded, Comparative Study of Injectable Micronized Dehydrated Amniotic/Chorionic Membrane Allograft for Plantar Fasciitis—A Feasibility Study. Foot and Ankle International. 2013



Living with Peripheral Arterial Disease

March 8, 2012


Definition of Peripheral Arterial Disease

Peripheral arterial disease (PAD) can be a debilitating disease. It is caused by fatty deposits that accumulate on the inner walls of arteries.  These deposits in the arteries of the lower extremity will result in poor blood flow to the legs and feet. If arteries are clogged and narrowed, blood will not be able reach its destination to supply muscles and organs with oxygen and nutrients. Decreased oxygen and nutrients to muscles can result in severe cramping in the legs, especially with increased workload such as walking. Patients with diabetes, high blood pressure, high cholesterol and smokers can be at increased risk of developing PAD. It is also important to note that persons, who have PAD, are also at increase risk of having fatty deposits in the arteries of the heart, which can result in a heart attack or stroke.


Symptoms of PAD

Most people with PAD are non-symptomatic.  However, if symptomatic, the most common complaint from patients with PAD is they get severe cramping or burning in the calf muscles when walking. Typically the cramping begins after one or two blocks of walking and will subside after a few minutes of rest. The cramping results from a build up of a waste product produced by exerting muscles called “lactate”. This is produced when there is not enough oxygen getting to the muscles. The cramping can significantly alter a patient’s lifestyle and prevent the patient from enjoying normal daily activities.  Aside from physical limitations, severe PAD can lead to non-healing wounds on the leg and foot and black/gangrene in the toes.  Some of these patients with PAD may require an amputation of the foot or leg.


Physical Examination for PAD

When a podiatrist evaluates a patient for PAD, there are key signs that are presented on the feet. Patients with PAD tend to have diminished or absent digital hair growth and nails that are brittle and thickened as well as decreased temperature in the feet. The podiatrist may ask the patient to hang their legs over the side of the exam chair, in patients with PAD the legs begin to display a deep purplish color. Patients with PAD will have a white, pale discoloration to the feet if the legs are elevated above the heart for one minute. The podiatrist will also feel the pulses in the feet. If the pulses are weak, it may indicate that there is poor blood flow to the feet. These are important signs that lead to a high suspicion of PAD.


Testing for PAD

The most common and least expensive office test for PAD is called an ankle-brachial index. This is done by taking the blood pressure of the arm (brachial) and comparing that number to the blood pressure in the ankle. This test requires a blood pressure cuff and Doppler ultrasound to hear the pulse.  The blood pressure cuff is inflated on both the arm and the leg. Next, the cuff is slowly deflated; the first sound heard in sync with the blood pressure number is recorded and compared by ratio. The normal ankle-brachial index is 1, in other words the arm and the ankle should ideally have the same pressure. Patients with an ankle-brachial index of 0.4-0.9 are considered to have PAD.  There are also additional tests that can determine poor blood flow. PAD can also be visualized with an MRI/MRA or angiogram, which requires injecting a dye through the blood vessels and using an imaging system to follow the dye through the arteries in order to visualize artery narrowing.


Conservative Treatment of Peripheral Arterial Disease

The most important goal in treating PAD in the lower extremity is to reduce the risk of amputation. Treatment is usually administered by the primary care or vascular physician. Drugs that thin the blood, such as aspirin, are often prescribed to patients with PAD to prevent the risk of clotting.  Smoking cessation programs and good control of cholesterol, blood pressure, and blood sugar levels are also strongly advocated. Foot care is also important in managing peripheral arterial disease to prevent ulceration to the feet. In treating cramping sensations from PAD, exercise therapy has been scientifically shown to increase maximal walking distance because it promotes small vessel formation around the area of the clot.


Surgical Treatment of Peripheral Arterial Disease

If the symptoms of PAD are severe, inhibiting lifestyle or resulting in non-healing wound or gangrene on the feet, surgical treatment may be required by the vascular physician. The goal of surgery is to increase blood flow to the legs and feet.  Surgical treatment may include bypassing the area of clot with a vessel graft or vein or opening the artery with a balloon and placing a stent to increase the diameter the artery and attempt to keep it open.


Tarsal Tunnel Syndrome and Treatment

March 20, 2011

Symptoms of Tarsal Tunnel Syndrome

Tarsal tunnel syndrome refers to the irritation and/or compression of a nerve called the posterior tibial nerve. This nerve is found behind the anklebone on the inner side of the foot.  (Same side as the big toe) As the nerve travels in this area it runs through small canal called the Tarsal Tunnel.

Symptoms of tarsal tunnel include:

1. Radiation, burning, or shooting pain on the bottom of the foot, along the arch and/or up into the leg

2. “Pins and needles” sensation to the bottom of the foot and into the toes

3. Disturbances in the perception of temperature (feelings of coldness)

4. Feeling like there is a tight band around the foot

5. Loss of sensation to the sole of the foot and/or heel

6. Pain getting worse with prolonged standing or walking

7. Rest and leg elevation can relieve symptoms

Causes of Tarsal Tunnel Syndrome

The main culprit of tarsal tunnel syndrome is the decrease in space in the tarsal tunnel, which results in compression of the posterior tibial nerve. There are multiple reasons that can cause narrowing of the tarsal tunnel.

1. As the tibial nerve travels behind the anklebone, it goes through the tarsal tunnel, which is a narrow canal bordered by a sheath of tissue and the heel bone.  As the tibial nerve goes through the tarsal tunnel, it usually splits into two nerves, the medial and lateral plantar nerves. If the tibial nerve splits into two nerves before entering the tarsal tunnel, it increases the number of structures going through the tarsal tunnel. This results in a relative decrease of space in the tunnel and compression of the nerve.

2. Several tendons and veins course through the tarsal tunnel with the tibial nerve. If these structures are enlarged or swollen the tibial nerve can be compressed.

3. Compression of the tibial nerve can also occur from bony prominences, spurs or fragments of bone in the tarsal tunnel.

4. Abnormal heel position with the heel positioned more inward or outward can stretch the tibial nerve or narrow tube of the tarsal tunnel again resulting in excessive pressure on the nerve.

Physical Examination in Tarsal Tunnel Syndrome

Tarsal tunnel syndrome can mirror other foot conditions, such as heel pain, arch pain, or neuropathy therefore, the podiatrist may need to utilize various examination techniques, imaging modalities and electro diagnostic studies to diagnosis tarsal tunnel and syndrome. The podiatrist will tap along the course of tibial nerve to reproduce the shooting sensation often associated with tarsal tunnel syndrome. The podiatrist will also examine if there is any swelling along the tarsal tunnel and the medial arch because this may indicate a mass that may be in the tunnel. The podiatrist may also try to increase the pressure on the tibial nerve by turning the foot outward and up and holding this position for 5-10 seconds. This exam produces a narrowing the space of the tarsal tunnel and can recreate the patient’s symptoms. Heel and foot position may also be examined to determine if that may be the cause of tarsal tunnel compression. In order to determine which nerve branches are involved, a pin prick test may be applied to the sole of the foot to determine which areas of the foot has decreased sensation.

Diagnostic Studies in Tarsal Tunnel Syndrome

If a bony prominence is suspected as the cause of tarsal tunnel syndrome, the podiatrist may request X-ray imaging of the foot and ankle. For soft tissue masses or increase tendon size/swelling, MRIs may be requested as well. Ultrasound may also be utilized to determine the tibial nerve split or tendon pathology. If vein enlargement is suspected, the podiatrist may use a tourniquet wrapped above the tarsal tunnel to increase fluid accumulation in the veins.  Other studies that may be ordered to study the function of the tibial nerve are nerve conduction studies or electromyography.

Non-Surgical Treatment of Tarsal Tunnel Syndrome

The podiatrist may recommend taping, bracing, orthotics, or shoe modifications to provide support to the feet and correct the heel position.  Correcting the abnormal foot movement that may cause stretching and pressure in the tarsal tunnel may prove to relieve the symptoms of Tarsal Tunnel Syndrome. Icing and oral anti-inflammatory may be suggested to decrease swelling in the area.

Surgical Treatment of Tarsal Tunnel Syndrome

The main purpose of tarsal tunnel surgery is to release structures that may be putting pressure on the posterior tibial nerve or removing bone or soft tissue masses that may cause narrowing in the tarsal tunnel. The incision is made behind the anklebone and in front of the Achilles tendon. During surgery, blunt surgical instruments are utilized in order to avoid damage to the nerves. The sheath of the tarsal tunnel is opened and the course of the tibial nerve and its branches are followed in order to remove any thickened structures and release any tight structures around the nerves. Following surgery, a bulky dressing is applied to the foot in order to decrease swelling. One week after surgery, simple motions of the ankle for 10-20 minutes twice a day may be recommended to prevent adhesions. After 2-3 weeks, sutures are removed and ambulation with tennis shoe may be allowed.  The average time for most patients to begin exercise and full activity is 2-3 months after surgery.  It is also important to note that tingling and pain may increase after surgery, and the pain and numbness may take up to one year or more to resolve

Tailor’s Bunionette and its Treatment

September 5, 2010

Most people know that a classic “bunion” appears as a bump on the side of big toe joint. A Bunionette or tailor’s bunion is like the big toe bunion, but in this case there is a bony prominence on the outside of the foot at the base of the small toe. The term ‘tailor’s bunionette originated from tailors in Asia who sat on the ground with their legs crossed resulting in increased pressure on the outside of their feet. This increased pressure caused thick skin formation on the outer aspect of the foot.

Anatomy of a Tailor’s Bunionette:

The fifth or little toe sits at the end of a long bone called the fifth metatarsal.  At the junction of these bones is the joint where the bunionette forms.

Causes of Tailor’s Bunionette:

There are many factors that cause a tailor’s bunion. Structural causes of tailor’s bunion can be an enlarged fifth metatarsal head. Increased angles between the fourth and fifth metatarsals can also cause this deformity. Finally, bowing of the fifth metatarsal may also lead to a Tailor’s bunion.  Or some combination of the above may contribute to the cause.


Tailor’s bunions may or may be painful deformities. If pain is present, it usually occurs with shoes. The area becomes painful when the bony prominence of fifth metatarsal head rubs against the shoe, resulting in pain and inflammation. Continued shoe friction against the tailor’s bunion can cause swelling, redness and callus formation. On examination, there is pain when pressure is applied to the outside or bottom of the fifth metatarsal head. A fluid-filled pouch, called a bursa, may be found between the bone bump and the skin. This forms as a process of the body’s protective mechanism to protect the bone against the friction from the shoe.


The diagnosis of a tailor’s bunion is based on physical exam and imaging. X-ray imaging is performed to evaluate the increase angle between the fourth and fifth metatarsals. This diagnostic tool is also used to determine how much of the bump is composed of bone and how much is do to the swelling from the above mentioned bursa sac.

Conservative Treatment:

Non-surgical treatment is used to decrease the pain and inflammation from a tailor’s bunion. This includes anti-inflammatory medicines, steroid injections. Pads and shoe modification such as a wider toe box or softer materials are used to decrease pressure on the area.

Surgical Treatment:

Surgery is indicated when conservative treatment fails to eliminate the pain. There are several surgical techniques used for the treatment of this deformity. The type of surgery performed will depend on a patient’s medical condition, findings on physical exam and the structure of the fifth metatarsal as determined by X-ray imaging. Surgery for a tailor’s bunion can be performed on the metatarsal head (the end toward the toe), shaft (the middle of the bone), or metatarsal base.

If the problem is found to be an enlarged metatarsal head then this area can simply be shaved down. If there is an increased angle between the fourth and fifth metatarsal bones this angular relationship may need to be changed. Therefore, this condition may need further modification by making a cut across the metatarsal and shifting the end of the bone. After shifting the cut section of the metatarsal, a screw may be used to maintain the position. If there are significant angular abnormalities between the fourth and the fifth metatarsals, then a surgical procedure at the base of the bone with screw fixation may be required.

Expectations After Surgery:

When the procedure is performed on the metatarsal head or shaft, immediate weight bearing in a post-op shoe is allowed. However, procedures performed on the metatarsal base are more disabling and need to be non-weight bearing with crutches. After surgery when returning to the doctors office for post operative care, follow-up X-rays to evaluate bone healing will determine when walking may begin. Additionally, as with all surgeries there will be swelling, pain and tenderness after the procedure. Medicines to control the post-operative pain and swelling will be available to the patient. Some of the inherent risk associated with this surgery are that the deformity may return or that there may be an under correction of the deformity.

Relieving Dry, Cracked Skin in the Feet

June 12, 2010

The skin contains a balance of water and fat to ensure its health. However, once this balance is disturbed, the skin can become dry and cracked.  This imbalance results in the inability of the skin to stretch properly. Extreme dryness of the skin can cause cracking. Since the skin is a protective barrier for the body, the cracking can lead to painful lesions and a potential area for bacteria to hide and cause infections. Thus, hydrating the skin is very important in maintaining the overall health of the body.
Symptoms of Dry Skin:
Generally, dry skin is dull and appears tight. In cases of severe dry skin, the texture can be rough with flaky scales and cracking.  This can result in itchiness, skin breakage, and pain.

Causes of Dry Skin:
Dry skin is caused by many factors, these are categorized in two ways. There are causes that are from outside of the body such as climate (low temperature and low humidity), environment, lifestyle, and age.  The second category are causes from inside the body such as genetics, medication, hormone changes, and disease. Additionally, dry, scaly skin can be a result of fungal infections that may be treated by a podiatrist with prescription anti-fungal medications.

Cracking of the skin is commonly found on the heels of the feet. This is caused by the enormous amount of body pressure that occurs when the heel strikes the ground. Therefore, the heels, more than any other part of the foot, need the most attention and daily care.

Since there are so many medications used to treat dry skin, the choice of what to use can be overwhelming. One thing holds true for most dry skin treatment; the goal is to increase water content of skin. Skin moisturizers, also known as emollients, maintain the skin cell connections, and thus, decrease scaling and cracking.

1. Skin Ointments: This treatment is greasy and does not mix well with water. Ointments are the most effective product and longer lasting, but may be undesirable because of its greasiness.

2. Skin Creams: This is the most common type of moisturizer. Creams can be blended with water. This form of therapy may be preferred over ointments due to the ease of application and the nature of the cream to blend into the skin.

3. Callus Ointments: This type of treatment for dry skin can be plant based or chemical based. Plant-based callus ointments remove and soften thick, dry skin using plant enzymes and are safe for diabetics. Chemical based callus ointments are used to remove and moisturize the skin at the same time, especially thick skin. However, caution must be noted when using chemical-based callus ointments because it can cause increase breakdown of skin in diabetics and are NOT recommended on open wounds, infected area, or inflamed skin.

4. Foot pumice stone followed by moisturizers: Foot pumice stones are recommended to be used in the shower when the skin has softened by the contact with water. The stone is rubbed against the skin, and produces friction that removes the thick skin.

5. Scalpel Debridement on Thick Skin: If the skin thickness is painful and severe, a podiatrist may use a scalpel with a blade to remove the dry hard skin. However, it must be noted that the use of a scalpel should be performed by a professional.

Ways to Decrease Dry Skin:
1. Avoid hot long showers and baths because the hot water can melt the natural oils out of the skin. Once the oils have been depleted continued contact with the water will suck the moisture from your skin.
2. Apply emollients to the skin daily
3. Use of humidifiers to keep moisture in the air can prevent dry skin
4. Wear socks to bed
5. Do not pick at dry skin because it can result in damage to the skin and cause an infection.
6. Avoid wearing non-supportive sandals for long periods of time

Fungus Among Us

May 24, 2010

Fungal infection of the nails, also known as onychomycosis, is a very common foot condition treated by podiatrists.  This condition is usually found in older patients. It is reported that 60% of people over 40 years old have evidence of fungus in their toe nails.  Fungal nails are white to yellow in color and cause the nail to become thickened and lose their normal shape. Nails that have become abnormal in shape are called dystrophic.  If the infection is severe, the thickened nail can begin to crumble. These infected thickened nails can also result in pain and discomfort when wearing shoes.

Lab tests for fungal nails:
The presents of thickened dystrophic nails maybe an indication of a fungus infection. However, they can also occur in patients with a skin condition called psoriasis. Sometime, thickened nails can occur in patients with damaged nail roots due to major trauma such as a having an heavy object fall on the toe. More commonly, the trauma can be delivered to the toe in small doses, this is called micro trauma. This is caused by jamming the toenail into the top of the shoe. This kind of micro trauma is often associated with runners and people who wear narrow pointed shoes. Thus, before prescribing any creams, solutions, or oral medication to treat fungal nails, the podiatrist must send a sample of the nail to the lab to confirm the presence of fungus.

Prescription treatment of Fungal Nails:
Using prescription medications to treat fungal nails usually takes many months before any improvement is seen in the nail. This is due to the long life cycle of the fungal organism and the slow growth of the toe nail. Most anti-fungal drugs attack the replication or reproducing cycle of fungus. Therefore, the improvement will only be seen in new growth of the slow growing nail  Thus, a great deal of patience is required in treating fungal nails. It is also important to realize that after the completion of anti-fungal drugs, there can be a recurrence in fungal infection.

Common Types of Anti-fungal drugs:
Terbinafine also known as Lamisil is the most potent anti-fungal drug used for fungal nails. It is easily distributed by the body into the nail via the nail root. Since terbinafine is broken down in the body by the liver, it is essential that a liver function blood test is performed before starting this drug. Patients with liver problems should not use terbinafine since this can result in severe damage to the liver. Thus, the podiatrist must request a blood test before prescribing this medication and during the course of the medication. The drug is taken once a day for 3 months. If side effects such as stomach or abdomen pain, diarrhea, rashes or headaches occur, the podiatrist should be notified. Lamisil will work to cure the fungus about 77% of the time.

Itraconazole (Brand name is Sporanox) is another oral anti-fungal drug that prevents the fungus from building its skeletal structure. The course of this treatment is 3 months as well. Additionally, this drug interacts with other medications, so a complete list of current medications should be given to the podiatrist. Cure rate is about 66%.

Ciclopirox 8% lacquer is an anti-fungal solution that is applied to the entire nail and 5 mm of surrounding skin for 12 months. This prevents the fungus from receiving its nutrients needed to grow. Common side effect is redness around the nail.  There is a cure rate of 29%-36% with this medication.

During the course of the treatment for the fungal nails patients should follow the a hygiene protocol.
Wash the feet two times a week with Betadine and soap. (As long as there is no history of Iodine allergy)
Use anti-fungal foot powder in the socks.
Change socks every day.
Use a fungal spore killing agent in the shoes such as Micomist by Gordon Labs, as directed.

Management of Fungal Nails:
For patients with poor kidney/liver disease, prescription medication may worsen these medical problems. Oral anti-fungal medication can decrease kidney and liver function. Thus, the best option in these cases may be routine nail debridement by a podiatrist. The podiatrist will cut the thickened fungal nails with special nail clippers, which then may be followed by grinding and filing of the nail by using a sanding disc or burr. The routine nail debridement usually requires the patients to return to the podiatrist about every 3-4 months.

Prevention of Fungal Nails:
1. Wear sandals when using public showers
2. Alternate shoes every day
3. Change socks daily
4. Avoid sharing shoes or socks

Final Thoughts:
Lasers for the treatment of fungal nails. This therapy has become very popular in the last two years. There are currently two types of lasers being used to treat fungal nails. The first uses patented technology to attack the fungal spoors. The other laser uses infrared light waves to cause light or photo damage to the fungal cells.
At this time the have been no large studies to prove the effectiveness of these treatment modalities.  At this time, there are multi-center studies in progress to accurately determine the cure rates for the use of lasers on fungal nails. However, until these studies are published there is no evidence based proof that lasers can successfully treat this condition.

Plantar Warts and its Treatment

April 9, 2010

Plantar warts are a very common non-malignant (not caner) skin condition found on the feet. These skin lesions are caused by various types of human papillomaviruses (HPV). The formation of plantar warts begins when the HPV enters cuts or cracks on the bottom of the foot. Plantar warts commonly appear on areas of increased pressure such as the heel or ball of the foot. If the plantar wart is found on an area of high pressure, the wart becomes thickened. It then grows into the foot and can become painful with walking and running. Another characteristic of plantar warts is they usually form in small clusters called satellite warts that radiate from a larger plantar wart.

Physical Exam of Plantar Warts:

Plantar warts can be confused with skin melanomas (cancer), which can be harmful and/or life-threatening if the cancer cells spread. They may also be confused with calluses, which form due to increased pressure to the feet. The skin lesion will be examined for presence of skin lines and color. If the skin lesion is thickened and multicolor, skin melanomas are suspected and a skin biopsy is performed to confirm the finding. In contrast to skin melanomas, plantar warts usually appear uniform in color. When comparing plantar warts to calluses, plantar warts do not have skin lines and will bleed if the area is shaved down with a scalpel. Additionally, patients with plantar warts will show signs of pain if the wart is squeezed as opposed to direct pressure applied to the top.

Treatment of Plantar Warts:

Plantar warts can be very difficult to treat because certain treatments affect each type of human papillomaviruses differently. To add to the difficult treatment of plantar warts, HPV has become more resistant to current treatments. Fortunately, there are many options to treating plantar warts, starting from a more conservative, non-surgical care to surgical solutions of excising the skin lesion.

First line of treatment:

The first line of treatment of plantar warts is over-the-counter solutions, creams, or patches containing salicylic acid like Trans-Ver-Sal or Duofilm. The acid softens the thick hard skin so that a pumice stone or file can be used to rub off the plantar wart. The advantages of using an over-the-counter product are its low cost and minimal discomfort. The disadvantage of using the products is the duration of the treatment and its dangers to diabetics and/or patients with circulatory problems. The whole course of treatment usually requires a diligent and regular application for a minimum of 3 months.

Second line of treatment:

A second line of treatment is cryotherapy. The wart is frozen with chemicals until a 1-2 mm white halo surrounds the plantar wart. This procedure is performed at the podiatrist office every 2-3 weeks.

The next method of treatment in the second line is Cantharone compounds. Using this method, the podiatrist will first shave all of the excess callus tissue from the top of the wart. Next the Cantharone compound is applied, allowed to dry and then covered with a band-aid. When possible, pads will be applied around the treated area to off load pressure. Usually, there is no pain when the compound is applied. Within 3 to 7 hours the compound works into the skin and will begin to burn. After about 24 to 48 hours, a blister will form. As the blister forms this area can become quite painful. The blister is usually deeper than a common water blister and may appear white, yellow or dark in color. When the blister is forming, the patient is encouraged to soak the area. Once the blister is formed the patient should try to puncture the blister and release the fluid. During the first few days, and possibly as long as a week, the treated area can be painful and the patient should continue using a pad to keep pressure off of the blister.

Another second line treatment is a prescription cream, such as Aldara, containing the active ingredient, imiquimod or Carac cream containing the active ingredient, fluorouracil. The imiquimod in the Carac cream activates the body’s immune cells that fight bacteria, viruses and destroy the HPV cells. The precaution to Aldara cream is that pregnant women and children under the year of 12 years old should not use it. The duration of Aldara cream treatment is a maximum of 16 weeks. Creams with fluorouracil inhibit viral growth and stops the HPV in plantar warts from growing. The duration of this treatment is about 2 weeks. For both topical treatments, irritation, itchiness, and redness to the skin can occur.

The last therapy in the second level of wart treatment is injections of Candida antigen into the lesion. Approximately 0.3cc of the antigen is injected directly into the wart. This works by initiating a local allergic response. When the patient’s body reacts to the allergen, antibodies are sent to the area and will try to destroy the Candida particles. These same immune cells will also attack the wart tissue. This procedure is done in the doctor’s office every other week and could take up to seven treatments. The down side to this treatment is the patient may occasionally feel flu like symptoms the day after the procedure.

Third line of treatment:

The third line of treatment is the surgical removal of warts. This procedure is performed in the podiatrist office and requires local anesthetic injections to numb the foot.

A curette, a small spoon-like instrument, it is used to scoop out the infected tissues and scrape out the viral cells that are embedded in the skin. Finally, phenol (a powerful form of alcohol that burns tissue and stops bleeding) may be used to kill the viral particles from the plantar wart and decrease bleeding from the procedure.

The area is then covered with gauze and bandages. After this procedure is done the patient is required to decrease pressure on the foot to alleviate pain and allow the area is heal. After the surgical procedure, the patient will need to return to the podiatrist office in order to follow the effectiveness of the procedure and to evaluate the healing progress of the wound. The disadvantage to this treatment is there is a possibility a painful scar may form at the site of the surgery.


1. Avoid walking barefooted in public showers or swimming pools

2. Avoid sharing shoes and socks

Buying Athletic Shoes for Your Foot Type

February 28, 2010

Buying athletic shoes can be a very daunting task, especially with the never-ending options of shoes found at stores. However, there is a science to athletic shoes, so you can find a pair that are best for you and decrease the chances of injury to your feet with some fundamental knowledge.

Before buying an athletic shoe, you must know what type of foot you have. Of course, there are subtle differences in everyone’s feet, but in general, there are three main foot types and athletic shoes, subsequently, are made for each of these foot types.

Foot Types:

1. Neutral foot: A neutral foot has a medium arch, which allows the pressure and force of running to be evenly distributed throughout the foot.  Additionally a neutral foot has an adequate amount of pronation, a movement that occurs during weight bearing where the bottom aspect of the arch moves toward the floor. Therefore the arch gets lower and the foot is more flexible in a pronated state. Since a neutral foot has the necessary amount of pronation, this foot is flexible enough to absorb the pressure of running and walking and adjust to changing terrain.  Also, a neutral foot has an adequate amount of supination. Supination is a movement of the foot where the arch of the foot rotates off of the floor creating a higher arch and a more rigid foot. With an adequate amount of supination, a neutral foot is rigid enough to push off the ground without causing injury. Recommended shoes for a neutral foot type are stability shoes.

2. Over Pronated/Flexible foot: This foot type has a very low or flat arch, which increases pressure on the inside of the foot and big toe during walking or running. This usually results in an increase of skin thickness on the inside of the big toe and ball of the foot.  Also, this type of foot is more flexible than a neutral foot. In the pronated position the foot is not rigid enough to push off the ground. Since an over pronated is a more flexible foot, motion-control running shoes are recommended for this foot type.

3. Over Supinated/Rigid foot: An over supinated foot has a very high arch, which increases pressure throughout the heel, the outside of the foot and ball of the foot. Compared to an over pronated foot, an over supinated foot is rigid and is not able to absorb the forces applied to the foot than the other foot types. An over supinated foot/rigid foot type benefits more from a cushion running shoe.

Shoe Types:

1. Motion control shoes: This type of shoe is best for patients with excessive pronation or a flat arch. The back of the shoe that cups the heel is known as a heel counter. The heel counter in a motion control shoe is rigid to prevent excessive pronation that occurs in a flexible foot. Additionally, the outline and shape on the bottom of motion control shoe is straight and broad at the front of the foot.  This shape is also designed to improve stability like have a wide wheelbase on a car.

To test a motion control shoe, grasp the heel counter with your hand and squeeze the heel counter. The heel counter should not deform with compression of your hand.

Another way to test for motion control is to grab the front of the shoe with one hand and the back of the shoe with the second hand and twist the shoe. The shoe should not deform with the twisting motion. The final test to determine the amount of motion in the shoe is to bend the front and back of the shoe together like a book. The bend of the shoe should be at the ball of the foot where the foot pushes off the ground during activity and should not bend in the middle of the shoe.

2. Cushion shoes: This type of shoe is best for patients with excessive supination or a high arched rigid foot. Cushioned shoes decrease pressure on the feet by absorbing forces transmitted from the ground while running. The outline and shape on the bottom of cushion shoes tend to curve at the front of the foot with extra padding at the front and middle of the shoe. Additionally, cushion shoes tend to have an hourglass shape when looking at the sole where the middle part of the sole is narrower than the front or back. Compared to motion control shoes, it is easier to twist a cushion shoe. Additionally, when bending the front and back of a cushion shoe together like a book, the bend is also at the ball of the foot, but the amount bend is greater and easier to perform than a motion control shoe.

3. Stability shoes: This type of shoe is recommended for a neutral foot type. This shoe has components of both a motion control shoe and a cushion shoe. The outline and shape on the bottom of stability shoe is semi-curved at the front of the foot. This type of shoe has cushion for absorbing forces from activity, but also like motion control shoes, has a firm heel counter, but is not as rigid as a motion control shoe.

General Shoe Fitting Rules:

1. Measure both feet standing

2. Try on shoes later in the day when feet are more swollen

3. Try on shoes half a size larger to compare fit

4. Leave one finger width from the end of the longest toe to the end of the shoe

5. Wear the shoe indoors first for 10 minutes or more to make sure it is comfortable

6. Shoes should not need a break-in period they should be comfortable when you try them on.

7. Make sure nothing pinches you inside the shoe

8. Do not wear a shoe for the first time in a race.

Replacing Shoes:

Shoes should be replaced about every 300-500 miles of running or walking or 45-60 hours of a sport activity. If there is creasing around the shoe lining, new athletic shoes must be considered. Another test to determine when to replace shoes is by seeing whether or not the shoe is uneven when it is placed on a flat surface.

Podiatrist: Get on your feet

December 5, 2008

Fitness SeriesAs 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.

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

November 18, 2008


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.