Posts Tagged ‘podiatrist’

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.

References

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

 

Peripheral Neuropathy and Diabetic Foot Ulcers

April 3, 2014

 

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What is peripheral neuropathy?

One of the major complications associated with diabetes is peripheral neuropathy. This process of nerve damage gradually takes place after many years of having diabetes and uncontrolled blood sugar. The condition affects the sensory, motor, and autonomic nerves of the body. Muscle strength and balance are diminished with motor neuropathies. While autonomic neuropathies manifest as loss of hair and disfunctioning sweat glands in the lower extremity and can present as erectile dysfunction in very advanced cases. Sensory deficits, which include numbness, tingling or even pain, are often the first symptoms to develop. Many people that are developing the condition may not notice the gradual onset of symptoms. Diabetics may be unaware of of these gradual changes until their doctor informs them that they have the condition. Some may experience shooting pains in their feet that become worse at night, making it difficult to sleep.

 

Lack of sensation in the lower extremity can be very dangerous because it increases the risk of developing sores, open wounds and ulcers on the feet. If the wound becomes infected, there is a likelihood that the infection can spread and amputation of the affected limb may be necessary if it is not treated soon enough. Losing a limb becomes a large burden for patients in their daily activities and adds additional costs to their medical care. Because of this, it is recommended that a comprehensive foot exam be performed annually in all diabetics.

 

Muscle weakening associated with motor neuropathy acts as an added detriment because it can lead to development of foot deformities, such as hammertoes, bunions or limitation of motion in joints of the lower extremity. These defomities may rub on shoe gear and cause skin breakdown. Coupled with a numb foot, these deformities increase the patient’s risk of developing foot wounds.

 

Foot exam

The physical exam involves a thorough review of the skin health, blood supply, nerves and muscle strength of the lower extremity. The skin is assessed for hair growth, any discoloration and wounds. Diabetics have an increased risk of developing poor blood supply also known as peripheral vascular disease. This in turn greatly increases their risk of acquiring a dangerous infection and non-heeling wounds of the feet. The neurological portion of the exam involves measuring the patient’s ability to feel a small flexible fiber under their feet with their eyes closed. Additional testing evaluates their ability to detect vibratory sensation. Patients that develop peripheral neuropathy may not be able to tell the doctor when the bottom of their feet is touched with a monofilament. These patients are at an increased risk of developing unnoticed foot wounds.

 

Diabetic foot wounds – how are they treated?

Repetitive trauma to the foot leads to development of a hard callus, which increases pressure on the foot when the patient walks. The person with a numb foot continues to exert pressure on the callus, which forms a deeper wound that can subsequently lead to infection. An ulcer develops when a break of the skin occurs. The depth of the wound plays a large role in how serious the infection can be and how it can be managed. A rim of callus usually surrounds the wound. Once the wound becomes infected, the foot may become red, leak fluid, and may have a foul smell. As the infection progresses, thick yellow fluid can leak from the wound. It is important that callus and any wound is medically evaluated and appropriate medical treatment is started as soon as possible. Initial treatment involves debriding the wound to remove any dead tissue covering in order to expose the underlying healthy tissue in the wound. Any callus that surrounds the wound is also removed. A culture is obtained to find out which bacteria are involved with the infection so that appropriate medical therapy with antibiotics can be initiated. Negative pressure wound therapy a small vacuum placed over the wound can be used in some cases to quicken the healing process. Some of these infected ulcers may require intervenous antibiotics and hospitalization.

In addition to antibiotics and debridement pressure from the shoe and the ground must be reduced or eliminated to allow the wound to heal. Offloading pressure from the wound sight is accomplished in many ways. Sometimes a wheelchair or crutches are needed to completely remove weight from the foot. An orthotic or shoe insert with cutout areas under the wound can reduce pressure from causing additional damage. There are also many other ankle-foot braces and cast that remove pressure from the foot. One of these braces is the Bledso Boot. This boot has a layer of auto-molding foam in the foot bed, which reduces pressure on the wound. It also prevents movement at the ankle therefore reducing friction that can cause tissue breakdown. Another type of device made to eliminate pressure from the bottom of the foot is called the Toad Brace. This apparatus is molded to fit and grip around the top of the lower leg and the knee. This construct floats the foot off the ground and completely offloads the bottom of the foot. After the wound heals it will be necessary to use an offloading orthotic and a shoe designed to fit this inner sole.

If you have peripheral neuropathy, it is important to check your feet daily for wounds. Areas of your feet that receive high pressure may develop calluses, which increase the risk of a wound forming in that area. Seek help early from your doctor so that a proper treatment regimen can be started. A wound that is deep and does not heal leads to further complications, such as bone or systemic infection. Disregard for the condition of your feet, especially if you are diabetic, can lead to loss of a limb.

 

Achilles Tendon Injury

April 12, 2013

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Definition

The Achilles tendon plays an essential role in the day-to-day movement of an individual no matter their level of physical activity.  This tendon connects the muscles of the calf to the heel bone, and helps to raise the heel when standing or flexing the foot away from the body.  It is a very thick band of tissue and can be easily seen and felt along the back of the lower leg, behind the ankle.  Without the Achilles tendon, it would be hard to do simple activities such as walking, running and jumping.

Damage to the Achilles tendon can lead to pain in the back of the lower leg, just above the heel.  Injury usually occurs when there is a sudden increase in stressful force on the tendon.  The three most common types of Achilles injuries are Tendinopathy, Partial Tendon Tear and Complete Tendon Rupture.

 

Achilles Tendonopathy

The term Achilles tendonitis is very commonly used to describe injury to the tendon that has not progressed to partial or complete tear.  The suffix “-itis” is used to describe a state of inflammation, which indicates a very specific sequence of reactions that occur when the body is injured.  Thus, the word “tendonitis” refers to the inflammation of a tendon.  Although tendonitis is often a cause of tendon pain, damage to the Achilles tendon does not always involve inflammation; the disease of the tendon is sometime caused by chronic degeneration.  Therefore, the term “Tendinopathy” which includes all categories of tendon disease, with or without inflammation, will be used in this article to refer to Achilles tendon injuries other than partial or complete tendon tear.

Patients suffering from Achilles tendinopathy will often complain of pain or stiffness just above their heel.

Partial or Complete Rupture

When an intense stress is suddenly placed on the Achilles tendon it can rupture or tear.  The amount of stress needed to tear the tendon can depend on the individual.  Even seemingly small increases in stress, if brought on suddenly, can cause a tendon rupture.  Athletic activities that may result in a tear include sudden pivoting or activities that involve quickly accelerating and decelerating.

Patients who suffer from partial or complete tendon rupture may describe hearing a “pop” followed by sudden pain.  Experiencing sudden pain and a loss or decreased ability to raise the heel increases the probability of a tendon rupture.  It is possible to have a tendon rupture without experiencing pain, so patients complaining of pain in the back of the heel or decreased ability to raise the heel should be evaluated for possible tendon rupture.

Physical Exam

A proper physical exam must assess the patient’s complaints and rule out all other potential diagnoses.  The Achilles tendon should be palpated for any signs of tenderness, thickening/thinning, swelling or other abnormalities.  If pain is present, it is typically felt 2-6 cm above the attachment of the tendon to the heel bone.

In every instance of Achilles injury, it is important to evaluate the tendon for possible rupture.  The tendon should be tested with the patient standing and off weight bearing in order to assess any loss of function.  Specific tests like the Thompson Test (squeezing the patient’s calf while they are relaxed on the exam table with their feet off the table) can be used to check for tendon rupture.

Imaging

X-ray and Ultrasound imaging can be used to evaluate the degree of tendon injury, and may help rule out other possible causes of the patient’s complaints.  If there is a high suspicion of tendon rupture, MRI imaging is frequently used to assess the severity of the tear and to help plan for proper treatment.

Treatment

Achilles tendinopathy can often be treated non-surgically.  Patients should avoid any activities that might cause pain or worsening of symptoms.  Ice can be used whenever symptoms occur, and nonsteroidal anti-inflammatory drugs (Ibuprofen for example) may be recommended.  Shoe wear modifications, inserts or medical orthotics may be used to help prevent continual injury.  Patients may expect to gradually return to normal activity over the course of 6 to 8 weeks.  Stretching, physical therapy, and laser treatment may also be recommended.  If the pain is severe, a CAM boot may be required for several weeks.  If the Tendinopathy does not resolve within 3 months, the patient should be re-evaluated.

Partial or complete tendon rupture may require surgical care.  Ice, pain medication, rest and immobilization of the ankle are used initially until surgical care is deemed necessary.  Once a patient suffers an Achilles tendon rupture there is an increased risk of repeat injury.

Platelet-Rich Plasma Injections

Platelet-Rich Plasma (“PRP”) injection is a relatively new therapy that has been developed to treat various forms of injury.  Concentrating platelets and other growth factors that contribute to the healing process which are naturally found in the blood forms the PRP.  The blood is taken from the patient.  Spinning the blood at high speeds separates the different components of the blood.  Once separated, the portion of the blood rich in platelets and growth factors is extracted and injected into the site of injury.  Studies have shown that PRP injections into acute injuries may increase the speed of recovery, and injections into long-standing (chronic) injuries may cause the body to renew the healing process.

The application of PRP injections are still being investigated, but the treatment has already been used for various forms of injury with positive results.  PRP treatment has been used to help treat Achilles tendon injury, and is typically reserved for patients who fail traditional therapy.  PRP injection therapy may not be for everyone, and treatment must be considered on an individual basis.

Source Material

Achilles Injury

Alfredson, H; Lorentzon, R.  Chronic Achilles tendinosis: recommendations for treatment and prevention.Sports Med. 2000;29(2):135.

Jozsa, L; Kvist, M; Balint, BJ; Reffy, A; Jarvinen, M; Lehto, M; Barzo, M. The role of recreational sport activity in Achilles tendon rupture: A clinical, pathoanatomical and sociological study of 292 cases. Am J Sports Med. 1989; 17(3): 338.

Gravlee, JR; Hatch, RL; Galea, AM.  Achilles tendon rupture: a challenging diagnosis. J Am Board Fam Pract. 2000; 13(5):371.

Maffulli, N.  The clinical diagnosis of subcutaneous tear of the Achilles tendon: A prospective study in 174 patients.  Am J Sports Med. 1998; 26(2):266.

Mayer, F; Hirschmuller, A; Muller, S; Schuberth, M; Baur, H.  Effects of short-term treatment strategies over 4 weeks in Achilles tendinopathy.  Br J Sports Med. 2007; 41(7):e6.

Khan, RJ, Carey Smith, RL. Surgical interventions for treating acute Achilles tendon ruptures. Cochrane Database Syst Rev. 2010.

PRP Injections

de Jonge, S; de Vos, RJ; Weir, A; van Schie, HT; Bierma-Zeinstra, SM; Verhaar, JA; Weinans, H; Tol, JL. One-year follow-up of platelet-rich plasma treatment in chronic Achilles tendinopathy: a double-blind randomized placebo-controlled trial. Am J Sports Med. 2011 Aug;39(8):1623-9.

Griffin, LY.  Treating tendinopathy with PRP.  AAOS. 2010 Sept; 7(3). http://www.aaos.org/news/aaosnow/sep10/clinical2.asp .

Mautner, K; Colberg, RE; Malanga, G; Borg-Stein, JP; Harmon, KG; Dharamsi, AS; Chu, S; Homer, P. Outcomes after ultrasound-guided platelet-rich plasma injections for chronic tendinopathy: a multicenter, retrospective review.  PM R. 2013 Mar;5(3):169-75.

Monto, RR. Platelet rich plasma treatment for chronic Achilles tendinosis.  Foot Ankle Int. 2012 May; 33(5):379-85.

Soomekh, D; Yau, SK; Baravarian, B. A Closer Look At Platelet-Rich Plasma For Achilles Tendon Pathology. Podiatry Today. 2011 Nov; 24(11):50.

Storrs, C.  Is Platelet-Rich Plasma an Effective Healing Therapy? Scientific American.  Dec 18, 2009. http://www.scientificamerican.com/article.cfm?id=platelet-rich-plasma-therapy-dennis-cardone-sports-medicine-injury.

Living with Peripheral Arterial Disease

March 8, 2012

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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

Alleviating Foot Pain

December 20, 2010

Pain can interfere with normal daily activity and can prevent us from enjoying life fully. However, pain is the body’s alarm system to alert us when something is wrong, and it is a normal response produced by the body.

How does pain work?
There are four major stages with which pain will begin in our body. The first is the actual stimulus, which starts the pain information pathway to the brain. The stimulus is usually negative and results in tissue damage. The damage can be a cut of the skin, a broken bone or a tear or crush of soft tissue.
During the transmission stage, this negative stimulus is converted by the nerves to an electrical signal. This information is then carried by nerves toward the brain.
Before the electrical information finally enters the brain, the body has a third step in the pain route, called modulation. The modulation step works like a gate, where the brain sorts out the various stimuli that the body receives and determines whether or not the signal is strong enough to be recognized.
Once the brain accepts the electrical signal and final process begins, which is the awareness of pain in the body.

What are the goals of treating pain?
The two main goals that a podiatrist wants to achieve in treating pain are to eliminate the source of the problem and also to treat the symptoms caused by the problem. In order to do so, the podiatrist will need to investigate the cause of the pain by first asking the patient a series of questions regarding the problem. Below is a series of questions that podiatrists commonly ask in order to find the source of the pain and how to better treat it. Patients should think about some of the answers to the following questions before and during the appointment in order to better assist the podiatrist in finding the source of the problem.

1. Where is the pain located?

2. How would you describe the pain?
There are different types of pain in the body. If the pain is tingling or burning, the problem is most probably associated with the nerve. Most likely, achy, dull, throbbing, or sharp pain, more often indicates more of a muscle or bone problem.

3. On a scale of 1-10, 10 being the most painful, what is your pain level?
Knowing the level intensity of the pain can help determine what type of medication to alleviate the pain. Stronger pain intensity may mean that a stronger strength of pain medication may be needed.

4. How long has the pain been occurring?
The duration of the pain can help the podiatrist determine whether the pain is acute, lasting for a few days to weeks, or chronic, which lasts for a period longer than 3 months. If the pain is acute, it may signify that there was trauma that occurred to the area. Chronic pain may indicate arthritic changes or overuse injuries of the foot.

5. Did you injure your foot or was there anything different that occurred before the pain?
Knowing the incidences before the occurrence of pain can help determine what structures in the foot are injured.

6. What makes the pain worse or better?

7. What treatments have you done to alleviate the pain?
Knowing what type of treatment a patient has tried helps the podiatrist know how to better treat the patient, especially in avoiding treatments that have already been tried. Additionally, if there may be two causes to the pain, it can help a podiatrist eliminate one of the two sources of the pain.

What are the common treatments for pain?
Aside from treating the source of the problem, the podiatrist may offer treatment that can alleviate pain.

1. Icing and compression. Increased swelling and inflammation to the foot caused by trauma can make the pain worse. Accordingly, icing and compression of the foot may be recommended.

2. Topical Anti-inflamatories: Botanical anti-inflammatories can also be used to reduce swelling and therefore reduce pain. Arnica is one of these topical plant products that can help. It comes from the Arnica Montana plant. It was discovered and used my native Americans before the arrival of Columbus and is still used successfully today

3. Non-steroidal anti-inflammatory drugs (“NSAIDS”). NSAIDS are commonly prescribed to control inflammation and swelling. They are often recommended for mild or moderate pain level intensities. Caution must be taken when using “NSAIDS”. If the patient has a history of stomach ulcers this class of drugs can increase the chance of a gastric bleed. It is important for everyone taking this class of medicine to take the pill with food. If stomach discomfort occurs, it is best to change the medication.

4. Opioids. Opioids do not decrease inflammation. However, they do decrease the amounts of chemicals that need to be released to start the electrical signal for pain. This prevents pain signals from entering into the brain. Opioids are often recommended at higher pain level intensities. When using, opioids caution must be taken to avoid drug abuse.

5. Capsaicin. This is a topical cream or solution that is applied to the skin and recommended more for chronic pain. Capsaicin has chemicals that are made from chili peppers. It decreases the chemicals that are needed for the nerves to transmit pain signals to the brain. Caution must be taken to avoid eyes, mouth, and genital areas when using this medication because it causes a severe burning sensation.

6. Local anesthetics injections. This type of treatment directly affects the nerves and prevents the nerves from sending signals to the brain. Local injections, however, only produce temporary relief.

7. Steroid injections. This type of injection is given in combination with local anesthetics and is another form of treatment to decrease inflammation. Depending on the problem, this type of injection can alleviate pain anywhere from a few weeks to a few months.

Treatment of Sinus Tarsi Syndrome

September 18, 2010

Where and what is the sinus tarsi:

The word “sinus” refers to a cavity, most often in bone. The cavity known as the sinus tarsi is located on the outside of the foot in front of and below the outside anklebone. The cavity is formed at the junction between the heel bone and the bone that sits over the heel bone called the Talus.  The heel bone forms the floor of the cavity and the talus creates the roof.

Within the cavity there are blood vessels, nerves and ligaments.  The ligaments function to hold the two bones together.

Symptoms:

“Sinus Tarsi Syndrome” refers to a painful condition located in this cavity in the rear portion of the foot. The pain is made worse with weight bearing. The pain can become much more intense when walking, running or hiking on uneven surfaces.

Causes of Sinus Tarsi Syndrome:

The most common cause of sinus tarsi syndrome is an inversion injury to the foot. This occurs when the foot rolls inward and stretches the soft tissue in the cavity.  When the foot is stressed by this inward motion a tear or strain occurs to the ligaments. The injury to these ligaments results in inflammation, swelling and thickening.

The other causes of this condition are structural as apposed to the injury noted above. One of these structural abnormalities that can occur is growths or masses of soft tissue.  Over growth of nerve or fat tissues in the cavity can cause increased pressure and result in pain. The pain in this area can also be caused by deviations in the bone structure. For example, bone spurs; arthritis and bone bridges can be responsible for the development of sinus tarsi syndrome.

Another helpful procedure to determine the exact location of the pain is to inject the sinus tarsi with a small amount of local anesthesia. If upon examination after the injection the pain is gone the diagnosis is confirmed. If however, the pain is still present following the injection the injury may be in another location in the foot.

Non-Surgical Treatment:

Research has shown that a majority of the people with sinus tarsi syndrome will respond favorably to conservative management. Rest, ice and compression are suggested to reduce the inflammation. Oral anti-inflammatory medications can be prescribed to further decrease the pain and swelling.

Another treatment option is to tape the foot to attempt to limit the motion at the subtalar joint. If the taping successfully reduces the pain long term treatment with a custom orthotic can be used to control the motion of the rear foot. In most cases foot orthotics are sufficient to treat this condition, however in some cases an ankle foot orthotic may be necessary to fully control the motion.

Finally, a steroid injection into the sinus tarsi may be effective at relieving the pain.

Surgery:

In conservative measures have not helped to relieve the pain surgery may be needed.  A common surgical procedure to threat this condition is decompression or removing the abnormal tissues from the cavity. If the MRI scans shows a soft tissue mass present in the sinus tarsi surgical removal of the mass will be needed.

After the surgery, protected weight bearing in a post-operative shoe or walking boot will be required for a period of approximately 2-4 weeks.

If this surgery fails or the patient has severe arthritis the bone in the rear foot may need to be fused.

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.

Symptoms:

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.

Diagnosing:

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.

Behind the Scenes of Foot Surgeries

June 30, 2010

This article will inform the reader about the various steps that will occur on the day of your surgery. Knowing the procedures and the processes and what goes on the operating room should help make you feel more comfortable. The following description details a patients experience from the time they come into the surgical facility through the surgery and finally the discharge back to your home.  You will also meet and understand the roles of the people who will help you and be involved with your care throughout your surgical day.

Before Surgery:
You will check in with the surgical facilities reception personnel. After filling out the appropriate forms you will be escorted to the changing area. In the changing area there will be a secure place to keep your property. Even though this is secure, it is advisable not to bring valuables to the surgery. In the changing area there will be a private room where the patient surgical gown will be provided for you to change into.  After this step, you will meet with the nurses who will perform a pre-surgical interview.  They will also take your temperature, review your chart and check your blood pressure and other vital signs.

Next you will be seated in the waiting area. When it is time for your surgery you will meet with the anesthesiologist. He or she will ask you questions regarding allergies, physical conditions and if you are a female of child bearing age they will ask if you are pregnant. At this time the anesthesiologist will have you sign a consent form to administer the anesthesia. The podiatrist will also meet with you and will mark the location on your foot where the surgery will be performed. At this time, the doctor will answer any last minute questions you may have.

During Surgery:

Next, you will be escorted to the operating room (OR).
The anesthesiologist will then start a connection through an IV into your arm to deliver the anesthesia. After you are in a dream-like state of anesthesia, the podiatrist will draw out the incision site on your foot, and inject the local anesthetics to the site of surgery.
The podiatrist will then go to the scrub station to disinfect their hands and lower arms.  Also at this time, the circulating nurse will use anti-bacterial sterilizing solution to clean your foot. The purpose of this cleaning is to create a sterile field on and around the surgical site so that it is free from bacteria and therefore minimize the risk of postoperative infection.
The podiatrist and first assistant will then be gloved and gowned by the scrub nurse. All the gloves and gowns are completely sterile, which is another way to reduce the possibility of infection that could enter your body.
The podiatrist and first assistant will place a sterile drape, with an opening for the foot, over your body. This further provides a surgical area is bacteria-free.
Before the podiatrist makes the skin incision, the circulating nurse will call a “Time Out.” This is when the nurse confirms your name, the surgical procedures and location, your allergies, and the names of the podiatrist and first assistant to everyone in the room. This may seem repetitive, but through research, this provides further safety for the patient.
The podiatrist may then wrap an Esmarch bandage (looks like a very wide rubber band) around your foot to squeeze the blood out of the foot. Inflating a tourniquet around the ankle then follows this and the Esmarch band is removed. This prevents bleeding during the surgical procedure and allows the surgeon to clearly see structures in the foot.
The designated surgery is then performed, whether it is to fix a hammertoe or bunion deformity or other foot condition.
At the end of the procedure the incision site is closed with stitches and bandages are applied on the foot. Depending on the type of procedure, you may leave with a walking boot or surgical shoe on your foot.
The anesthesiologist will slowly withdraw the medication and you will soon regain consciousness.

After Surgery:
You are transported to the recovery area.  The surgeon will meet with you again to follow-up on your status.
Depending on the type of anesthesia used, you may or may not be groggy at this time. Therefore, you may or may not remember seeing the surgeon in the recovery area.
In the recovery area the nurse will monitor your progress as you return to full conscientiousness. As soon as you are able, they will get you to out of the bed and into a chair. When you are fully aware and awake the nurse will go over your postoperative instructions. Once you are able to ambulate, you will be discharged and released to proceed to go home.

Who’s Who?

Circulating Nurse: Works outside the sterile field in the operating room. Cleans the surgical site with anti-bacterial solution and performs the “Time Out” before the incision is made. Also, the circulating nurse opens all instruments and stitches in a sterile fashion for the scrub nurse and brings in any instruments that may be needed for the surgery. Documents and counts all the instruments and stitches used during the procedure. At the end of the surgery, the circulating nurse assists the Scrub Nurse in making sure all the gauze and instruments are accounted for.

Scrub Nurse: Gloves and gowns the surgeon and first assistant and hands the surgeon and first assistant the instruments, stitches, and bandages needed during the procedure.

First Assistant: Assists the surgeon in holding back the soft tissue during surgery and helps with instrumentation and orienting the patient for the surgeon to access the surgery site easily.

Anesthesiologist: Provides pain medication and monitors breathing rate, blood pressure, and heart rate and rhythm during the surgery.

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.

Treatments:
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