Serious Diabetic Foot Infections: Osteomyelitis

Diabetics are prone to several types of infections. One common and serious infection is osteomyelitis, which is an inflammation of bone. Such a problematic condition eventually causes death of the bone and surrounding tissue, leading to amputation, IF NOT CAUGHT AND TREATED EARLY.  At the first sign of an infection:  redness, pus, inflammation, heat and pain.  Osteomyelitis is often chronic in diabetics and must be constantly monitored.  It is commonly spread from a foot ulcer to the bone, if untreated. Signs of an infection of an ulcer include discharge, swelling, redness, tenderness or pain, and warmth to touch. If not treated swiftly, this can most definitely progress to osteomyelitis. Risk factors include deep wounds, neuropathy, Charcot’s foot [loss of the internal orientation of the bones, exuberant bone growth], poor blood circulation, poor control of sugar, and immune dysfunction.

The most common bacteria that cause osteomyelitis are Staph aureus. It is difficult to treat this type of bacteria because it is part of what is known as a biofilm. This is a community of bacteria protected by a matrix. The matrix is difficult to penetrate and so many antibiotics cannot damage the bacteria. The antibiotic, furthermore, must be able to also penetrate bone, which is the deepest tissue. The most common antibiotics given for osteomyelitis are penicillin’s and the closely related cephalosporins. If the patient has a penicillin allergy, Clindamycin or Vancomycin can be given. The antibiotic is usually administered with an IV in an outpatient setting. This is because the therapy must usually be done for a long time, and it also prevents gastrointestinal problems. Along with the antibiotic therapy, debridement or removal of the dead infected tissue must be done in order to break down the biofilm of the bacteria.  There is a relatively new antibiotic, linezolid (Zyvox®) which is given orally and very effective for the treatment of a particularly virulent type of Staph:  MRSA (methicillin resistant staph aureus). 

Especially when the infection becomes chronic, surgery may be necessary to treat osteomyelitis. Reconstruction of the limb is done in several different ways depending on the progression of the infection. Sometimes adjunctive therapy like revascularization of the limb or using hyperbaric oxygen therapy (HBO) is useful. However, the best chance of a positive outcome is when surgery, debridement, and antibiotics are used collectively.

 

At the first sign of a suspicious ulcer, drainage, a deep looking wound, consult your Podiatrist or PCP immediately.

Rao, Nalini, Ziran, Bruce, Lipsky, Benjamin. “Treating Osteomyelitis: Antibiotics and Surgery.” American Society of Plastic Surgeons Vol 127 Number 1S (2010): 177S-187S.

Very interesting article about "Cosmetic Foot Surgery". 

Read and check our website at www.myfootdoc.com

http://www.ibtimes.com/press-release/20121205/plastic-surgery-feet-latest-baltimore-fashion-trend-says-cosmetic-surgery

DIABETES AND YOUR FEET, Part II of III

DIABETES AND YOUR FEET

~Written 9-11-12 … never forget~

Diabetes affects millions of Americans and their daily lives.  One cause for concern with this disease is the damage done to the feet from high sugar levels, mainly nerve and blood vessel damage.  This makes the diabetic patient more susceptible to infection from poor wound healing.  In addition, Diabetes can have a detrimental effect on the kidneys, eyes as well as the feet.

However, there are several day-by-day routines that you can do to protect your feet from an infection that can become catastrophic:

          •         Check your feet every day.  If you are obese, have a family member check, or buy a floor mirror that you can put your feet close to and see the bottom surface.  If your vision is poor, an inexpensive way is to get a pair of +3 reading glasses from your local drugstore.  A magnifying glass can help as well.  Often a patient has such bad nerve damage that he cannot feel any cuts or blisters.  If I had 5 cents for every diabetic patient who walked in with a tack or diabetic syringe needle in their foot and could not ‘feel’ it – I’d be quite wealthy!

          •         Rub lotion to promote moisture, but do not put it in between toes because this can cause infection.  Be sure the lotion is ‘diabetic approved’.  Many brands are available and often, urea based creams are the safest as they have humectants – products that pull water into the skin.  Avoid Lanolin based creams.

          •         Always wear shoes, slippers or socks around the house to protect feet from injury.  Make sure all your shoes fit properly.  Look for 'diabetic socks' which are of natural fibers, breathe and do not have rubber to cut off your circulation.

          •         If nails are not infected with fungus, cut toenails once a week in between doctor visits.  Clean the nails before cutting them with alcohol.  Make sure the clippers are clean and rub with alcohol or a dab of household bleach.  Avoid nail salons – unless you have some that ‘sterilize’ – check with your doctor or local social media site to see what 'like minded diabetics' have to say about the salon.  Make sure to cut nails straight across and avoid the corners - and tell your pedicurist the same!

     •         Develop healthy habits to keep your sugar levels under control, such as a healthy food and exercise plan.  Monitor your blood glucose every single day and take any medications prescribed by your physician.  Exercise and a good diet are your best friends and the best way to lower blood sugar.  Many useful 'exchange' diets are available on the Internet and from the American Diabetes Association.

Most importantly, make an appointment with your doctor as soon as you notice any problems.  Unfortunately, diabetes is a very serious disease and one instance of an unnoticed wound can spiral into something quite serious.  You should think of your feet as we all think of our teeth – they should be checked by a foot specialist at least twice a year when one is a diabetic.

“Prevent Diabetes Problems: Keep Your Feet and Skin Healthy.” National Institute of Health Publication No 08-4282 (2008)”

THE ARTHRITIC BIG TOE

THE ARTHRITIC BIG TOE

Many people take their big toe … called hallux in medical parlance, for granted. It is not intuitive that this structure of the foot is significant to how we walk and the amount of pain we may feel during walking. One of the most common problems with the big toe is hallux limitus. This deformity is defined as less than 65 degrees of dorsiflexion (flexing the toe upwards) at the joint between the metatarsal bone and the phalanx bone. Hallux limitus should be addressed immediately because it often develops into hallux rigidus, which is defined as less than 20 degrees dorsiflexion due to degeneration at the metatarsophalangeal joint. Decreased range of motion of the hallux particularly comes into play during propulsion, or when the foot leaves the ground while walking. Often hallux limitus or rigidus is seen with age, arthritis, and ‘wear and tear’, in many athletes and in contact sports such as soccer. It is painful due to the lack of motion or ‘push off’ when one moves forward in the gait (walking) cycle.


There are several causes of hallux limitus. For instance, a structurally long first metatarsal can cause jamming at the joint during propulsion. Furthermore, a common foot deformity called rearfoot varus, or when one walks too much on the outside part of the heel, causes limitus of the big toe if there is compensation present. This means that the person tries to walk more efficiently by putting more pressure on the inside of the heel. Although this seems beneficial, the compensatory movement leads to extra mobility and often elevation of the first metatarsal during propulsion, which consequently leads to limited dorsiflexion at the joint.


A popular conservative treatment for hallux limitus is an orthotic (custom arch insert) with a modification called Morton’s Extension. This modification is used to improve metatarsal function. If this bone is structurally elevated, the orthotic essentially raises the ground up to the bone in order to prevent the compensation toward the inside of the foot and jamming at the metatarsophalangeal joint. In other words, it reduces the excursion of the bone.


Many other treatments exist, such as: massage, linaments, stretching, physical therapy, ‘toe raise’ exercises, and gentle range-of-motion exercises which can be done at home. In addition, stretching before sports or a long walk can be beneficial. When conservative measures fail, surgery may be indicated. Since there is no ‘perfect’ solution, many procedures exist, some based on age, and others based on activities. These range from a ‘decompressive bunionectomy’ to a joint resection (Keller arthroplasty), to replacing the joint with an artificial joint (total joint replacement) to fusion of the joint to maintain length and reduce pain. A new technique we are using is a decompressive osteotomy that shortens the bone and increases the joint space – this improves range of motion while keeping the joint intact.

Adapted from Schoenhaus, Harold; Whitney, Kendrick.

ILIO-TIBIAL BAND SYNDROME

The IT band is a thickening of connective tissue on the outermost or lateral part of the thigh. It contributes to the stability of both the hip and knee. It is, therefore, quite prone to injury. IT Band Syndrome (“ITBS”) is common upon runner and cyclists. Stud-ies have shown that it is the most common running injury of the lateral part of the knee as well as 22% of all lower extremity injuries. Patients feel pain and tenderness in the knee caused by repetitive flexion of the joint. The IT band rubs against the part of the femur attached to the knee, causing friction and inflammation. This pain and discomfort often causes gait (walking) abnormalities.


There are several common mechanisms of injury for IT Band Syndrome. For ex-ample, weak hip abductor muscles, or the muscles that move the thigh outward to the side, will cause too much hip adduction, or the movement of the thigh toward the mid-line of the body. This occurs when the foot hits the ground while running. Many runners also over-pronate, or turn the ankle inward, which causes increased stress on the IT band. Other factors include increased knee flexion during downhill running or fatigue at the end of a run, too much internal rotation of the knee, and low hamstring strength when compared to quadriceps strength.

Few patients require surgical care, although removal of a cyst deep to the band may be necessary in some cases. But have no fear; there are several conservative treatment plans for IT Band Syndrome. First, limit your mode of activity. Relieve pain and inflammation with ice or anti-inflammatory agents, such as a corticosteroid or NSAID drug. Stretch the IT band by placing the affected leg behind the other while standing and stretching sideways away from the affected side. Finally, ask your doctor about orthotics, especially if you have over-pronation. Occasionally, an injection of local anesthetic and steroid (cortisone) will help in reducing the inflammation.



Try to improve your ‘gait’ by stretching, wearing the right type of running shoes and using orthoses when needed. Remember, your orthoses should be fitted by a pro-fessional (physician) much like a pair of prescription glasses. Avoid stores where you stand on a mat or where your foot is scanned – in those cases a ‘physician’ is not evaluating your gait cycle.





Lavine, Ronald. “Iliotibial Band Friction Syndrome.” Current Reviews in Musculoskeletal Medicine Vol 3 No 1-4 (2010): 18-22.

All you wanted to know about Achilles injuries.

What Really Happened to David Beckham and Can It Happen To You?

On Sunday March 14, 2010, the world’s most elite soccer player lost his chances of entering The World Cup due to a sports injury. This injury was an Achilles tendon rupture, often a career-ending injury for soccer, tennis, football and basketball players.

The Achilles tendon is made up of fibrous tissue bonded together in a ropelike manner. The tendon connects the heel bone to the calf muscle in each individual. It is the largest tendon in our body and is capable of bearing large amounts of weight. The function of the tendon is to pull the heel off the ground and allow the toes to push off the ground in order for us to make a step as the calf muscle tightens. The ‘tendon’ is actually a combination of the three muscles of the lower leg, often called the gastrocnemius complex. The ‘tendon’ is the terminal attachment of the Soleus Muscle, as well as the Medial and Lateral Gastrocnemius muscles. The action of the tendon/muscle group is necessary to allow walking, running, and different activities such as participating in sports. Once an interruption (tear) is made through this band of fibers, a simple task such as walking becomes unbearable. This condition is known as an Achilles tendon rupture. Bruising, swelling, redness, inflammation, pain and sensitivity in the back of the affected leg are just a few of the symptoms to mention that result after a rupture. Patient may also hear a sudden pop as the injury occurs. Often, patients relate being hit with a 2x4 or feeling like they were shot in the back of the leg!

The chances of a rupture increase as the tendon grows weak. This weakness can occur due to aging, medications such as corticosteroids (and some drugs known as Quinolones) as well as conditions like arthritis. With that said, it is important to know that tendo Achilles rupture is most common in middle aged men, especially those known as “weekend warriors” who play an extensive amount of recreational sports such as basketball, soccer, surfing, etc. after a long time of no activity. A sudden fall, a sudden push-off of the foot with the knee straightened can all result in injury.

It is important to seek medical care as soon as the injury happens. Podiatrists are trained to diagnose an Achilles tendon rupture by some important and simple clinical testing techniques. An MRI or ultrasound are then ordered to verify the rupture and determine the level at which the rupture has occurred. Once a rupture is confirmed, surgical and nonsurgical treatment plans are decided by the physician. Both are a long term course of treatment that can last about 6 months. Immobilization, casting, and physical therapy are some standards to achieve the ultimate goal of treatment which is restoring the original length and strength of the tendon.

A word of advice from your sports podiatrist: always RICE after any injury. To RICE is to Rest, Ice, Compress and Elevate the site of injury.

Unfortunately Beckham’s injury crushed his hopes for a chance to win at the world cup and is causing him to miss a big portion of the MLS season. We all wish him a full recovery to return to the sport that he loves most.

Diabetic Foot Care, Part I of III

There are several important things for a diabetic to keep in mind for both their general and foot health. Daily monitoring of blood sugar, and regular check-ups by your primary care physician are key factors to good health. Diabetics who are well controlled stave off some of the more adverse long-term effects of diabetes including: neuropathy (loss of sensation in the feet and hands), vision changes and kidney failure. Neuropathic changes in the feet can eventually lead to ulceration (large open wounds) and to amputation of the toe or leg. As the foot becomes neuropathic there is a loss of both the ability to react to pressure and to pain. Neuropathic changes are concerning because it can be considered a loss of protective sensation. When one loses the ability to feel, one looses the ability to help protect the body from danger. Your podiatrist can help you to identify any changes in protective sensation via testing with a Semmes Weinstein 10g monofilament. Once neuropathic changes are evident several things can be done at the home to help promote healthy feet. In addition, skin biopsies that measure the amount of nerve fibers “Epidermal Nerve Fiber Density - ENFD” testing can be done in the doctor’s office with a small amount of local anesthesia. These are excellent baselines tests to determine the fiber density and six-months later determine if medication is helping.

Some helpful hints:

1: Daily inspection of the feet, use a mirror to note any changes on the sole. Note any color changes, cracking, or any evidence of trauma. If concerning call.
2. Keep your feet moisturized by using a good foot cream, or lotion.

3. Check the bath water using your elbow or a thermometer, too hot of water can lead to burns to neuropathic feet and the hands.

3. Nails should be kept trim, cut straight across, and filed smooth. When the nails become problematic please have your podiatrist cut them or demonstrate the proper method of nail care.

4. A podiatrist should address any problematic corns and calluses, or lesions.

5. Wear supportive and properly fitting shoes. A protect slipper or shoe should be worn in the home. Don’t forget to wear socks.

Good foot health can be accomplished by teamwork with your primary care physician, your podiatrist and yourself.