Lets first get some terms out of the way before we discussed effective treatment options. Tendons are chord like structures that connect muscle to bones. They always cross at least 1 joint in the body and allow us to move our body parts. The most easily recognizable tendon is probably the Achilles tendon located in the back of the heel.

Tendinopathy, Tendinitis, and Tendinosis. These terms are constantly thrown around, but what do they mean. Tendinopathy is a general term used to describe any tendon injury, and nothing more beyond that. Tendinitis is probably the most commonly heard of term, and misused term. Tendinitis technically describes inflammation of the tendon and thats it. Usually there is no underlying damage to the tendon or long term consequences. However it is commonly used to by the public and doctors describe any tendon pain due to the familiarity of the term with the general public. Tendinosis is probably a more common pathology and describes a degenerative process caused by old injuries or overuse. Basically this type of tendon injury is more serious resulting in microtears of the tendon that build up over time, which can lead to severe pathology.

“when i doubt..it’s gout” is my motto

Gout can be one of the most easily missed diagnosis’s. As you may or may not know, gout is a painful inflammatory joint condition. While its most commonly found in the big toe joint followed, it can occur anywhere.

When patients ask me what gout is I usually compare it to diabetes. In diabetes, patients have problems processing sugar. In gout, patients have problems processing protein. Thankfully gout isn’t fraught with the long term complications associated with high blood sugars, but can nonetheless be very painful debilitating disorder.

Specifically, the pain and inflammation associated w/ gout is caused by Uric Acid (a by product of protein metabolism). Without boring you to death with the biochemistry behind the disorder, in short the Uric Acid crystals precipitate near a joint causes a red hot swollen joint. The reason the big toe is the most common is because its easier for uric acid to precipitate out in a cool environment, and naturally your big toe is a lot colder than your hip.

Treatment varies from patient to patient. It usually starts w/ diet modification and limiting protein and alcohol intake. In fact they used to call it “rich man’s disease” back in 1700′s because only rich people could afford to eat meat and drink alcohol, hence would be the only people that would suffer from this disorder.

Other treatments include reducing the inflammation with Colchicine, Indomethacin or a cortisone shot. Then for prophylaxis patients can be placed on either Probencid or Allupurinol to prevent this sort of thing from reoccurring.

…by far my favorite thing to treat in the office, as patients get immediate relief from treatment w/in 48hours.

Ingrown toenails come in 2 different flavors; infected and non-infected, with varying degrees of pain. All ingrown toenails are caused by the nail plate digging into the skin on the side of the nail. Some people nails are naturally more curved (a term we call incurvated) than others, and therefore are more prone in ingrown toenails in their lifetime. Nails can also become incurvated secondary toe nail fungus or trauma. A lot of pregnant and post-partum females are seen with ingrown toenails due to the pedal swelling caused by pregnancy. Lastly of course, there’s the dreaded ingrown toenails caused by digging in the corners by either the individuals themselves or at nail parlors.

No matter how you got them, there’s one of 3 ways to treat them depending on the situation. First there’s the “slant back” procedure. This procedure is reserved for mild cases of ingrown toenails that are non-infected. Usually the patient complains of at the front corner of the nail near the end of the toe. In this procedure we remove the offending portion of nail using a special surgical blade, and under the cold spray anesthesia thereby causing minimal pain.

The next procedure is a partial nail avulsion procedure with or without incision and drainage of abscess. In this procedure we use Lidocaine (a form of novacaine) to numb up the affected toe. Once the toe is numb and nail splitter is used to take a sliver of nail from the offending side, all they way back to the nail root. The piece of nail is removed, and the area is inspected of any abscess (ie. collection of infection fluid), and if there is some it is drained completely. This procedure is reserved for more moderate to severe ingrown toenails that are infected.

Lastly, is the Phenol and Alcohol procedure. This procedure is the same as the partial nail avulsion procedure, however can only be done in the presence of no infection. In this procedure, once the nail is removed, the nail matrix (which grows new nail plate) is burned w/ Phenol (a special acid) to kill those cells, thereby preventing that portion of the nail from growing back. This procedure is usually reserved for people w/ recurrent ingrown toenails.

Typically the post-op period for these procedures is painless. Patients are instructed on doing daily foot soaks for a period of 2 weeks after the procedure. Antibiotics may be indicated in the presence of infection.

Last time we talked about what a bunion is and how mild bunions are treated, most notably the Silver Bunionectomy or McBride Bunionectomy were discussed. Today i will discuss the most common procedure for mild-moderate bunion deformities the Austin Bunionectomy.

The Austin Bunionectomy was first described in 1962 by (you guessed it) Dr. Austin. Unlike the Silver Bunionectomy and McBride Bunionectomy, where only the bump is shaved off, Dr. Austin proposed making a cut across the metatarsal (in essence creating a surgical fracture), then moving the front end of the bone over to help reduce the bunion deformities.

Now this was nothing new at this point, as several doctors had described making a cut in the metatarsal and moving it over for correction of bunions. What Dr. Austin did differently was create a V-shaped cut. The shaped of the “V” allowed for more stable cut allowing for faster and more predictable healing.

In orthopedic circles his procedure goes by the name “Chevron Bunionectomy”, as the word Chevron is just a fancy word describe the letter “V” (think of the logo on the Chevron gas station).

By utilizing the a V-shaped cut in the bone, it allowed for greater and greater correction of bunion deformities. So much so that its the most widely used procedure in bunion correction today.

Today the 2 fragments are either pinned together (w/ an absorbable or non-absorbable wire) or fixated w/ a bone screw. Post-op usually requires 4-6 weeks on limited weight bearing in a special surgical shoe.

There is a whole host of treatment modalities out there for Toenail Fungus. Unfortunately, none has a success rate approaching even 90%. Which makes this one of the more difficult podiatric problems to treat.

Toenail fungus is usually caused by the organism Trichophyton rubrum. The fungus is everywhere in the environment, although most cases in young females seem to come from nail salons. In the elderly or immuno-compromised (ie Diabetes, HIV, Chemotherapy, etc) it is fairly common to see this condition. In it’s mild form, most people experience slight yellowing of the nail corners of the big toenail. In its most severe form it causes thick, discolored, flaking, malformed, painful nails. Obviously the more mild the case, the easier to treat, while some of the most severe cases require removal of the nail.

Treatment varies from patient to patient, case to case. It usually starts with an office visit, where we use a variety of sanders and burrs’s to remove and thin the affected nail, so that the recommend treatment has the best chance of working. The universally accepted best treatment out there right now is Lamisel. It’s an oral tablet that you take once a day for 3 months. Its success rate is close to 70-80% of the time. The downside of this product is that there is some risk to the liver. While the risk is minimal (has the same risk as taking Lipitor or other cholesterol lowering agents), we still like to monitor a patients liver function w/ lab work during the course of the treatment. The other oral therapy drug on the market is Gris-Peg, while not as effective at Lamisel, it is more likely to be covered by insurance plans.

For whatever reason, some patients can’t take the oral Lamisel or Grispeg (albeit it they don’t want to…or can’t accept the minimal risks to the liver). Which means the only option to them are varying topical’s. The most famous one being Penlac. Since Penlac is now generic it is accepted by most insurance plans. However, it is labor intensive treatment and only works 10-15% of the time. It’s a nail lacquer that the patient needs to apply every morning, and remove w/ alcohol every night for 48 weeks.

In our office we sell Formula 3, another nail lacquer which is oil based. It is a non-prescription medicine that requires application 1-2 times a day. Cost’s about $40 dollars, but it comes w/ a no questions asked money back guarantee if you don’t see results. We are also in the process of marketing Fungisel anti-fungal lacquer (topical form of Lamisel), which would cost roughly the same as Formula 3 with the same money back guarantee.

The new thing in treating toenail fungus is Laser. No conclusive scientific studies have been published proving the efficacy of this form of treatment. Therefore, insurance companies won’t pay or approve of this sort of therapy. Which means the out of pocket cost to the patient and can be as high as $800 per foot. Until there is more scientific proof of Laser therapy, we’ll continue to instead peruse the above therapies w/ patients.

Last line of defense are the home remedies. There are several home remedies that can be tried, most of which involve drying out the nail. Fungus likes dark moist areas to live, and the inside of your shoes is the perfect environment. The home remedy I recommend is to apply rubbing alcohol or apple cider vinegar on the affected toenail after showering, and spraying the inside of your shoes w/ Lysol to kill any fungus hiding there, and applying foot powder daily. I’ve also heard of patients success w Vicks Vapor Rub, Listerine (old school kind), and bleach. Most of these at home remedies require up to a year, and strict daily use to work.

“it feel’s like i have a burning rock in my shoe”

I hear that from a patient i think instant neuroma. A neuroma is a inflamed, irritated nerve that causes pain in the ball of the foot. Hearing the suffix “oma” usually freaks people out, but in this case its a 100% benign condition and nothing to worry about.

So what causes this condition. In the human foot there is 5 toes. Each toe is connected to 5 metatarsal bones. The metatarsal bones are the longest bones of the foot, and help transfer the weight from the hindfoot to forefoot during normal gait. Anatomically the distal ends of the metatarsal bones are known as the “metatarsal heads”, which forms the ball of the foot you see as you look at the bottom of your foot. The metatarsal heads are rounded portions of the ends of the metatarsal bones that connect to the toes forming the metatarsal phalangeal joint (ie MTPJ). From left to right, each metatarsal heads is connected to each other by a ligament called the deep transverse metatarsal ligament. Under this ligament, in between each metatarsal, runs a nerve that supplies sensation to it’s corresponding interspace. This nerve sometimes becomes entrapped between the two metatarsal heads and ligament becoming irritated and inflamed, resulting in shooting, burning pain and sometime numbness. The 3rd interspace is the most common followed by the 2nd interspace. This persistent irritation can cause scar tissue and bulging of the affected nerve, creating the term “neuroma” we use today.

Treatment is pretty straight forward for this condition. It includes a round of anti-inflammatory medications, ice to the foot daily, paddings, and a cortisone injections to the affected area. The above helps to reduce inflammation, thereby providing symptomatic relief. In some cases the pain doesn’t subside (or returns) and which case a MRI or Ultrasound is performed. Once the extent of the pathology is ascertained, surgical excision (for large ones) or radiofrequency ablation (for small ones) is performed to remove the neuroma.

Not talking about the New York Jets football team here, but instead the more serious complication of diabetes and/or smoking. Gangrene is defined as the necrosis or dying of soft tissue secondary to hypoxia (lack of oxygen). All cells and tissue in the human body require oxygen to survive. Oxygen is primarily delivered via small blood vessels called capillaries. When these capillaries are damaged, or the vessels leading to them blocked, it leads to death of the surrounding tissues.

Diabetes and smoking are the leading causes of gangrene. The high sugar content in the blood as well as nicotine, causes hardening and calcium deposits to form on the walls of blood vessels. Overtime the blood vessels will complete seal off, allowing no blood to flow through. When this happens in the bigger vessels there are procedures such as angioplasty, stents and bypass’s that can be down to alleviate the problem. However, when this happens in the foot, its termed “microvascular disease”, and as of now there is no treatment or cure.

Gangrene in the foot is usually seen in the tips of the toes first, as this is the area with the smallest blood vessels. Most patients experience excruciating pain, that is only relieved by hanging there leg of the edge of the bed. This allows gravity to bring blood down to where its needed. At this point several tests are ordered to pinpoint the extent of the disease. The easiest test is called Non-invasive vascular studies that we do right in our office. It includes using a doppler machine to take measurements of the amount of blood flowing through the arteries of the thigh, leg, and foot. What the doppler does, it measures that sound created by blood flowing through an enclosed space. In a normal vessel one should here a tri-phasic pulse, which means 3 distinct sounds with each heart beat. Anything less is considered diseased.

The doppler test is also done inconjuction with an ABI, also known as a Ankle-Brachia-Index. In basic terms a blood pressure is placed on the forearm and another on the thigh, leg, or foot. A ratio is derived from the 2 different blood pressure readings, and this further helps in our diagnosis of peripheral vascular disease.

If there is adequate blood flow for healing, then usually the patient will need to undergo amputation of the gangrenous digit. Depending on how much patients blood flow is available for healing, only part of the digit may need to be removed, or if the foot is severely diseased more will need to be removed.

“I think it may be a wart, Doc”…is what I hear a lot from patients these days. 99% of the time they are right, making it one of the more easily recognizable Podiatric conditions that we treat.

A wart is caused by the Human Papilloma Virus (HPV). There are over 120 different HPV types, and plantar’s wart gets the distinction of HPV-1. The virus only infects the epidermal (outermost) layer of skin, and is can be contagious. While most people get infected from communal showers and pools, a patient can contract it anywhere they walk barefoot.

Once a wart infects the skin cells, it generally causes the skin to form thicken calluses on the bottoms of the foot. Unlike hand warts which are raised, the plantar warts become inverted and are generally flat. Little blood vessels appear in the center of the wart, giving its hallmark “salt and pepper look”. In order to differentiate between and wart and callus, there are two methods. First, if there is more pain on squeezing the lesion side to side versus direct pressure than that is indicative of a plantar’s wart. Second, if there is pin-point bleeding when the lesion is shaved down, than that is also indicative of a plantar’s wart.

There are countless methods to treating a wart, ranging from high tech techniques such as Laser and Cyrotherapy, simple curettage and excising the lesion, powerful chemotherapy drugs such as F-5U, strong acids, and even some really bizarre techniques as duct-tape, and marigold flowers. We here offer a wide variety of options, but have the most success with Canthacur.

Canthacur’s active ingredient is Cantharidin, which is a chemical compound secreted by the blister beatle, which you guess it, causes a blister when it comes in contact with the skin. When applied to a wart, this blister helps destroy most of the virus in 1-2 applications. While an extremely effective treatment, patients often complain of pain to the area, 12 hours after its application, which will subside by the next morning.

The advantages of this treatment over the more common acids used in most office today, is that it requires fewer treatments, less patient compliance (no need for daily applications), and higher success rate.

Overall we’ve been pleased with its use an highly recommend it to all patients seeking treatment for warts in our office.

When patients see me for consultation for their bunions, they usually believe that all I have to do is “shave the bump off”. While a bumpectomy is a recognized procedure in the podiatric world, usually its only reserved for the mildest of cases, or the elderly. Of course we recommend that all patients first try conservative care including paddings, strappings, and wider shoegear before considering any surgery.

The term used for shaving the bump is called a Silver Bunionectomy. It was first performed at the turn of the 20th century. So it’s been around for about 100 years. Although simple and easy to perform (with a fast recovery time of 2 weeks), it most often fails to completely correct a moderate bunion. In which case, the deformity reappears in a few years, leaving the patient with unsatisfactory results.

In the 1920′s and 30′s a procedure was added to the Silver Bunionectomy, in hopes to “beefing” up the correction of the bunion deformity. This new procedure was called a McBride Bunionectomy. In addition to taking the bump off, a soft tissue tendon balancing procedure was performed. This helped to straighten out the big toe, giving a more satisfactory result to patients over the long term. However, it would still produce inadequate results for moderate bunion deformities.

It was not until the 1950′s that a procedure known as the Austin Bunionectomy would come to revolutionize bunion surgery today.

What is a Bunion? A bunion is a large bump or growth on the inside of your foot near the big toe. It is caused by the 1st metatarsal bone drifting outward, and the big toe drifting the opposite way. This dislocation of the big toe on the metatarsal creates that bump. It’s analogous to creating a “knuckle” on the side of your foot.

Think of it this way, if you flatten your hand on a table, the top of your hand should be flat. Now curl your fingers under and create a fist. You should see 4 distinct bumps on the top your hand (one for each finger). The same thing is happening in the foot, but only to the big toe.

In normal feet, the toes should be more or less straight. However, in a flat foot, the front part becomes destabilized due to over-pronation. This destabilization causes the big toe joint to drift out of place, creating the bump you see.

In medical terms this is defined as Hallux Abductus Valgus (ie HAV). Hallux is the Latin word describing the big toe. Abductus describes the position of the big toe, and is latin for “pull away from the midline of the body”. So in the case of bunion deformities the big toe is pointing away from the body’s midline (or center of gravity), hence the term. The word Valgus is another Latin word that describes the rotation the big toe undergoes. In this case, an outward rotation.

Usually these are painless foot deformities, although they can be cosmetically unappealing. In cases where there is pain, surgery is usually the most effective treatment. However, for mild cases there are some pads and strappings available to alleviate the pain.