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.

Gout!

Gout



“The Gout” James Gillray

Once called the “king of diseases, the disease of kings”, gout has been around since antiquity. Identified in 2640 BC by the Egyptians and later recognized by Hippocrates in fifth century BC, Gout is derived from the Latin word ‘gutta’ meaning ‘drop’.

Historically, gout is associated with an individual’s having the money to enjoy a diet abundant in meats, cheeses and wine hence the nickname of “Rich man’s disease”. A painful condition of the joints, gout is caused by increased levels of uric acid a product of purine [protein] metabolism. Foods rich in purines, such as meats and cheeses, certain wines and fishes, can help to precipitate gouty attacks. Gout is caused either by the body over producing uric acid or not being able to excrete uric acid fast enough to prevent build-up. Most commonly middle-aged men are affected by gout, although often the disease is seen in women. Hence the term ‘under-excreters or over-producers. This is often the way to tailor drug treatment to manage the gouty attacks and prevent a recurrence. Lab work and on occasion, a urine sample will help determine the type of patient and tailor the drug treatment.

The classical presentation of gout is described as a toe that is very red, swollen and warm. The toe is so painful that that even the touch of a light bed sheet is agonizing. Depositing into the joint space, uric acid crystals cause an inflammatory response responsible for the hallmarks of a red, swollen, and painful joint. Usually gouty attack occurs in one joint, most commonly the big toe (‘great toe’ or ‘hallux’). Gout of the big toe joint is known as Podagra. Drinking plenty of fluids, maintaining a healthy BMI (basal metabolic index = weight), and minimizing alcohol consumption can help to minimize gouty flare-ups. Typically, the painful joint resolves in several days with medications, dietary changes and rest. More information on diet can be found here: http://www.mayoclinic.com/health/gout-diet/MY01137

If the shoe fits ....

If the Shoe fits…. All good stories start with “Once Upon a Time” and end with a slipper and a “Happily Ever After” or so we are taught by the Cinderella story. Cindy was lucky she had a Fairy Godmother for the perfect fit, but what do the rest of us do when it comes to finding shoes? Several simple steps will make buying the next pair of sneakers, pumps or loafers a shoe-in.

1. Shoes go last: Shop for shoes at the end of your day as feet swell, increasing the size. A later fitting may lead to a more comfortable wearing shoe. It is also important to try on shoes while standing as your feet change shape.

2. Measures twice wear always: Measure your feet twice a year using either a Ritz stick or a Brannock Shoe Measuring Device. Both devices measure the width and the length of your foot. Your local podiatrist will be able to properly measure your feet, and help you in your shoe search. If you are at a shoe store, see if one of the sales-people is a “certified fitter”.

3. Ball to bend: The ball of your foot, which describes the joint of your big toe, should correspond to the bend in the shoe. You can test the bend of a shoe by holding the heel steady while flexing the toe box (where the toes go). The bend in the shoe should correspond with the bend at your big toe joint.

4. Wiggle room: You should have enough space to allow your toes to move. Your toes are an important agent in walking and help your foot to better support and balance the body.

5. Test so they last: Test the shoes before you buy them by walking/jogging around the store. If the shoe is uncomfortable in the store try a different size or forgo the shoe for something more comfortable. Then when you take them home, walk on a carpeted surface, testing the shoe again for a longer period of time. The carpet will prevent scratches to the bottom of the shoe, so you can return as necessary.

6. Diabetic Shoe: Don’t forget if you are a diabetic, you should look for shoes without seams inside. Your podiatrist can give you suggestions on brands of shoes or make you a ‘diabetic type’ shoe if you need this. In addition, avoid socks with too much elastic as these can cut off circulation to the feet.

May your shoes and your feet live “Happily Ever After”.

If the shoe fits ....

If the Shoe fits…. All good stories start with “Once Upon a Time” and end with a slipper and a “Happily Ever After” or so we are taught by the Cinderella story. Cindy was lucky she had a Fairy Godmother for the perfect fit, but what do the rest of us do when it comes to finding shoes? Several simple steps will make buying the next pair of sneakers, pumps or loafers a shoe-in.

1. Shoes go last: Shop for shoes at the end of your day as feet swell, increasing the size. A later fitting may lead to a more comfortable wearing shoe. It is also important to try on shoes while standing as your feet change shape.

2. Measures twice wear always: Measure your feet twice a year using either a Ritz stick or a Brannock Shoe Measuring Device. Both devices measure the width and the length of your foot. Your local podiatrist will be able to properly measure your feet, and help you in your shoe search. If you are at a shoe store, see if one of the sales-people is a “certified fitter”.

3. Ball to bend: The ball of your foot, which describes the joint of your big toe, should correspond to the bend in the shoe. You can test the bend of a shoe by holding the heel steady while flexing the toe box (where the toes go). The bend in the shoe should correspond with the bend at your big toe joint.

4. Wiggle room: You should have enough space to allow your toes to move. Your toes are an important agent in walking and help your foot to better support and balance the body.

5. Test so they last: Test the shoes before you buy them by walking/jogging around the store. If the shoe is uncomfortable in the store try a different size or forgo the shoe for something more comfortable. Then when you take them home, walk on a carpeted surface, testing the shoe again for a longer period of time. The carpet will prevent scratches to the bottom of the shoe, so you can return as necessary.

6. Diabetic Shoe: Don’t forget if you are a diabetic, you should look for shoes without seams inside. Your podiatrist can give you suggestions on brands of shoes or make you a ‘diabetic type’ shoe if you need this. In addition, avoid socks with too much elastic as these can cut off circulation to the feet.

May your shoes and your feet live “Happily Ever After”.

Ankle Sprains

Ankle Sprains & Treatment

Ankle sprains occur to anyone in almost any sport or activity. The majority of ankle sprains occur during contact sports with the top four being: basketball, football, soccer and running. But ankle sprains can occur in other activities such as in dance and even just walking outside on uneven sidewalks. Most of us ignore the sprain and take it easy for the next couple of days. But this type of “treatment” doesn’t treat the inflammatory process behind the sprain.

Inadequate treatment of an ankle sprain can cause the ankle to become prone to sprains and later can develop into lateral ankle instability due to the laxity of the ligaments around the ankle. The anterior talo-fibular ligament is the most sprained ankle ligament contributing to the instability. By taking care of an ankle sprain correctly with proper treatment will help reduce the risk of lateral ankle instability.

This can be prevented by using the simple acronym RICE that stands for:
Rest the injured ankle from any type of weight bearing activity and this is best accomplished by using crutches or even various casting options.
Ice the injured location for about 20 minutes at a time to help reduce swelling and to prevent further injury. A simple ‘frozen bag of peas’ or several ice cubes wrapped in a towel will suffice.

Compression by using a gel wrap or elastic bandage will help support the ankle.
Elevate the injured side by keeping it above the heart level, which helps to reduce both swelling and bruising.

By following the RICE treatment and by taking anti-steroidal anti-inflammatory drugs (NSAIDs) to help with pain management and reduce swelling and inflammation, the injured ankle will have a better chance of recovery and will prevent the risk of developing ankle instability. More severe ankle sprains that involve more ligaments and possibly bone will need the attention of a podiatrist. Trainer or your family doctor, who can evaluate the ankle with other diagnostic tools such as ultrasound and x-rays.

Please email us with any questions of comments.

What Do Summer and Sun Exposure Mean for Your feet?

Summer season is here and everyone is excited about spending some time in the sun. Whether it is just some play time with the kids in the backyard, enjoying the pool, or maybe even planning a vacation with the family and enjoying some peaceful time on a beautiful beach. Although, all of those scenarios seem like a way to spend a great summer, what many people tend to forget is protecting their skin from harmful sun exposure. We have all heard of the importance of protecting our skin from the sun due to the harmful UV radiation and the possibility of skin cancer. Unfortunately, any area of exposed skin is fair game for the cancer of the skin. It is hard to believe that skin cancer can also rise from the skin on our toes, feet, ankles, and legs. The number of individuals who forget to lather up the skin on those areas specially the toes and the feet might surprise you.

After prolonged sun exposure, irregular skin cells grow and begin to differentiate over time. If unattended and untreated, they have the potential of spreading to other parts of the body including other tissues and organs in a process called metastasis. Different types of skin cancer exist including: basal cell carcinoma, squamous cell carcinoma, and malignant melanoma; with basal cell carcinoma being the most common skin cancer amongst all. Melanoma, which rises from skin melanocytes, is the least common and yet the most dangerous type of skin cancer with the ability to metastasize.

Skin cancer presents itself in many forms, some common presentations on the foot include: scaly, shiny, waxy, crusty, or simply a small, red lesion. The areas that one should pay close attention to on the feet in terms of screening for potential skin cancer include but are not limited to the dorsum of the foot, area underneath/surrounding the toenails, and the heels.

Risk factors for skin cancer involve light-complexion and fair skin, family history of skin cancer, age (more common in those over the age of 40), and finally the areas that sunburn easy.

The ABCDE’s of skin lesions, are some important features to look for and they entail: asymmetry, border, color, diameter, and elevation of the lesion. Asymmetry is seen where one half of the lesion has a different appearance/texture compared to the other half. Be on the lookout for irregular borders of the lesion, a star like border is a common example. Color of the lesion should be assessed and any color difference compared to the surrounding skin should be noted. Any lesion with the diameter of 6mm or larger should be brought to your physicians’ attention. Last but not least, any elevation of any lesion is alarming.

Different types of skin cancer whether melanocytic or nonmelanocytic require a different type of treatment with some having surgical excision as the best definitive treatment approach. Early detection is the key with skin cancer as it is with many other health conditions. So, here is our friendly advice: enjoy your summer and your time off with your family, however, do not forget sun protection (at least SPF 30) and regular skin screenings. Try and stay out of the sun when UV rays are most intense, mainly between the hours of 11am and 3:30 pm. If a mole or a skin lesion on your lower extremities looks suspicious to you and fits the ABCDE criteria above, be sure and consult your podiatrist. Finally, have a fun, safe, and an amazing summer!

Platelet Rich Plasma Therapy: Way to a Rapid Recovery

Platelet Rich Plasma therapy (PRP) is a new way of healing that has been deserving of much debate in the past year upon its effectiveness. It is a non-surgical, cutting edge injection therapy that is to promote healing of bone, soft tissue, cartilage, and nerves. The injection is composed of platelet extracts from whole blood. Athletes such as Tiger Woods received several of these injections in 2009 to promote healing of a tendinitis condition that he had acquired after an Achilles tendon injury in the year prior. Another well known athlete that had the advantage of PRP therapy is Troy Polamalu who received the injections for the treatment of a strained calf after a knee injury.

PRP is able to promote healing by mediating the degree of inflammation in the affected area. After an injury is sustained by a tissue, an inflammatory response begins causing redness, heat, and swelling. This aids in preventing infection and allows the tissue to become prepared for healing. The healing process begins after the inflammation period is over. Platelets play a major role in both the inflammation and the healing process. Platelets are capable of inhibiting inflammation, and therefore allowing the healing process to begin much earlier by producing several growth factors in the tissue including those that aid to stimulate the growth of new blood vessels.

According to a research done by Dr. Grambert, of Indiana University School of Medicine, more than one injection may be needed for complete healing and results may be seen in as many as 4 to 6 weeks. He also has found success in treating patients with plantar fasciitis using PRP accompanied by a tear in the plantar fascia which aids in lengthening. Boot immobilization is then followed to allow the patient full recovery. This treatment regimen has provided his patients with promising results, where 85% of his 89 plantar fasciitis cases returned to normal activity with no limitations within six weeks.

Another advantage of PRP is that, it is an affordable treatment for most patients. Platelet Rich Plasma therapy is ongoing debate and it is currently being researched on in many labs and by many practitioners across the country, however, its promising results should not be foreseen.

Acquired Flatfoot in Adults

Recently, more and more individuals have been presenting to centers of foot and ankle care with the major complaint of pain and swelling in their medial ankle. This is mostly due to a condition known as posterior tibial tendon dysfunction (PTTD) which is the leading cause for acquired flatfoot in adults. The posterior tibial tendon provides stability to the medial side of the ankle joint by supporting the arch and providing support during walking. Impairment of this tendon is a progressive condition and results in PTTD. Methods of treatment vary within different stages of PTTD. If left untreated, partial and complete ruptures of the tendon may result.

Activities such as walking, running, hiking, climbing stairs, where the function of the tendon is required, as well as conditions such as hypertension, smoking, obesity, arthritis, diabetes and peripheral neuropathy can lead to the progressive dysfunction of the tendon. A condition known as equinus which may result from the tightness of the calf muscles of the leg may also contribute to the development of PTTD. Equinus results in the over working of the posterior tibial tendon during the gait cycle and therefore the weakening of the tendon over time.

Symptoms of PTTD include pain, stiffness, and swelling in the medial ankle. The pain is worst when the individual is weight-bearing or during activity. Progressive flattening of the foot and the outward turning of the forefoot in comparison to the rearfoot are also conditions associated with the tendon dysfunction.

Treatment methods vary within the different stages of the tendon dysfunction. At early stages where minimal amount of pain with activity is present, anti-inflammatory medications (NSAIDS), orthotics, and shoe modifications with arch support are appropriate and beneficial. Treatment for later stages of PTTD includes ankle braces, immobilization, walking casts, physical therapy, and finally surgical correction to prevent further damage to the tendon. If left untreated, fusion of the subtalar joint and other primary joints along the medial arch and the foot become necessary and lead to long term disability.

Presenting to a foot and ankle surgeon once symptoms begin to occur is of major importance in order to prevent further dysfunction, disability and the need for complicated surgical procedures.

Barefoot Runner: To Be or Not To Be

It seems that lately everywhere that media exists, there is a discussion of a hot new topic in the area of sports medicine and the current "tweet" is barefoot running. This technique has been utilized by some professional athletes and marathon runners. One particular individual who has become very famous through barefoot running is known as “barefoot Ken Bob”. True barefoot runners believe that barefoot running keeps their feet in their neutral position and therefore helps them with overall biomechanics of the foot, mainly their balance and stability. The strategy and the thought behind this is that all throughout history, our ancestors have been on their bare feet walking, running, working, and providing for their families. It was not until recently that the idea of supportive shoes came around. Later, orthotics were introduced along with their benefits of giving runners the opportunity to sustain less injuries and less pain while having the ability to run longer distances.

From a foot and ankle doctor's point of view, supportive shoes absorb shock from the ground while we run and they provide cushioning against hard surfaces; they increase stability and lessen the chances of injury. Furthermore, the use of custom orthotics perfects the biomechanics of our feet so that pressure is distributed equally and at the right phase of the gait cycle. Those average runners who currently use custom orthotics due to poor biomechanics will not benefit from barefoot running in any sort. In fact, they will only increase their chances of hurting themselves and sustaining an injury while running. On the other hand, those with good biomechanics who currently do not need the support of an orthotic may benefit to a certain level by barefoot running in a safe environment. Barefoot running is not at all suggested for diabetic patients, those suffering from peripheral neuropathy, peripheral vascular disease, heel spurs, previous foot injuries and plantar fasciitis.

There is much debate going on about this topic and until more research and study is done there will be no certain answer. The original research done on barefoot running showed that there is less damaging pressure placed onto the hips, the knees and the ankle joints while the patient walked barefoot on the treadmill compared to when they were walking in supportive shoes. What the article fails to do is to test this strategy on alternate surfaces for the patient.

What each individual needs to keep in mind is that our feet have become accustomed to the arch support, and cushioning provided by shoes. To take that and to suddenly go from great support to no support will exhibit an enormous amount of stress onto our feet; stress that the feet will not be able to handle and will therefore get injured. Forces anywhere from two to eight times of our body weight go through our body as we run, without the support of shoes, we will get hurt due to lack of adequate motion control and stability. If you are an individual who would like to experiment with barefoot running, start in a safe environment and start slowly. Also, keep in mind that certain shoes in the market mimic the mechanics of barefoot running and could possibly be a good starting point. Barefoot running is really like starting over and is a process that needs to be “eased into” in order to allow the body to adapt to the new forces being exerted onto it.

As physicians and podiatrists, we are most concerned about our patient’s health and want what is best for them. Further biomechanical studies are certainly needed to determine the best remedy for our professional runners. Until then, we will advise to our patients what we have been trained for and that is to have support at all times while walking and running to prevent injuries. Always remember the general rule of doing things in moderation and to consult a physician before starting any exercise regimen.

For further questions, call us at 713-999-6600 or view us online at www.myfootdoc.com.

Achilles Tendonitis and Achilles Tear

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.

-30-

Platelet Rich Plasma for Plantar Fasciitis

See so called "New" Therapy for plantar fasciitis, achilles tendonits, achilles tendonosis and other muscloskeletal conditions of the ankle & foot.

http://online.wsj.com/article/SB10001424052702304370304575151732675970098.html?KEYWORDS=prp

Well, this is our attempt at securing a small spot on the internet. We intend to write articles, tweets and posts regarding issues of sports injuries of the foot and ankle. For the Who, What, Where, check out our webpage: www.myfootdoc.com