A patient came in the other day with a swollen tip of her second toe. She also had a funny looking, thick toenail and really thought that was the cause of her pain and swelling. She related that she had been experiencing throbbing pain, redness and swelling for several months in just the tip of the toe. It had never spread or gotten much worse. She had never experienced drainage or infection symptoms around the toenail. She was unable to wear a closed in shoe and was to the point that she wanted her toe amputated. She had been treated with topical anti-fungals and antibiotics without much result. She was sent to me for another opinion after taking two months of oral anti-fungals and having no change in the nail or toe appearance. What a strange presentation....or is it?
Sausage toe is a whimsical term used to describe a red, hot swollen toe often seen in psoriatic arthritis. It can also be seen in Reiter's syndrome and other seronegative arthropathies. In English, a non-rheumatoid type arthritis. Sausage toe is inflammation of the distal interphalangeal joints (tip of your toe and adjacent knuckle) that looks like a sausage or lollipop. In psoriatic arthritis, it is often accompanied by nail changes that mimic onychomycosis or a fungus in the nails. The nails can be pitted, yellow, thickened, fragmented, and lifting from the tip of the toe. Psoriatic arthritic can occur without the typical skin changes seen in psoriasis, but most patients have some skin lesions.
Sausage toes should be treated aggressively to decrease the inflammation and joint destruction. Long term inflammation can lead to erosive changes and permanent joint pain and stiffness. Joint ankylosis (complete fusion of the joint) can occur in severe cases. Basic treatment starts with nonsteroidal anti-inflammatory drugs, exercise, physical therapy and education. Patient should be taught the "move it or lose it" principal of arthritis management. Exercise and mobilization of the joints, but not overuse and abuse, should be reinforced. Some patients need more aggressive treatment, and this should be part of a comprehensive treatment plan by a rheumatologist.
Sausage toes should not be ignored. They can be caused by many factors such as trauma, infection, osteomyelitis (infection of the bone), and many different rheumatologic disorders as discussed. If you experience a painful, red, swollen toe that just seems to persist; seek the opinion of your podiatrist. Treated early, sausage toe can just be part of a whimsical story instead of a long term disability.
Wednesday, September 30, 2009
Sunday, September 20, 2009
Ankle pain with no sprain?
I see several patients on a weekly basis that complain of ankle pain that have no history of recent ankle sprain or any trauma. They describe their pain as sharp and burning on the inside of the ankle with swelling and pain that is worse with walking, but continues as aching pain at rest. Some patients can have so much pain that they are unable to walk without crutches.
On exam, I will find that the posterior tibial tendon is swollen and painful usually from behind the ankle bone down to where the tendon inserts in the foot. The job of this tendon is to help the foot swing inward in gait and support the arch. But with flat feet, the tendon is overworked and often then forms small tears in the area just described which then causes pain and swelling. When asking a patient to walk in my office, the affected foot will show minimal to no arch height and the ankle will appear to be falling inward, sometimes almost touching the ground. There is usually pain with isolating this tendon on a muscle exam as well.
If you think you may have this condition, the physicians at Foot and Ankle Associates of North Texas are here to help!
Friday, August 28, 2009
Ugly Toenails Linked With Depression! New Treatments Are Available!
Many people suffer from a common problem: ugly, thick toenails. Often this is caused by onychomycosis, a fungal infection in the nails. Most people actually feel this is simply a minor cosmetic problem and really do not classify this as a disease. Reality is that onychomycosis can actually be a devastating problem for many people. In fact, a recent study has linked onychomycosis with depression in otherwise healthy patients.
Onychomycosis, over a period of time, makes your nails yellow, thick and often extremely disfigured. This is embarrassing and many people hide their toes in closed in shoes due to the disfigurement. Many people will even wear sneakers to the beach to avoid showing their toenails. Surveys have shown a lack of intimacy, decreased feelings of self-worth and depression associated with onychomycosis. With almost 30% of the adult population suffering from toenail fungus, and this number increasing to almost 90% in the elderly, why do most people feel it is just cosmetic? Because it hasn’t happened to them yet!
There is hope for people who suffer from toenail fungus. Traditional topical and oral therapies have been less successful than patient expectations. Lots of unhappy people with sever frustration!
Topical therapies patients have tried encompass a wide variety of products and folklore including the use of Vick’s Vaporub, organic cornmeal soaks, and a variety of over-the-counter products. Even the only FDA approved prescription topical, ciclopirox, is shown to be only 8% effective in their own package insert! Imagine painting your toenail with a topical therapy for over a year, every day, and still having ugly toenails!
After failure of topical therapy, most people discuss oral anti-fungals with their doctors. Common oral therapies include terbinafine, fluconazole, and itraconazole. These are more effective than any topical, but come with possible side effects including many drug interactions and liver problems. They are touted as somewhere between 50 and 70% effective depending on dosage and duration of therapy. Many people after taking these medications still have ugly toenails! More frustration!
Hope has recently increased for patients who have struggled with chronic onychomycosis. New laser therapy for onychomycosis is the most exciting treatment now available. A pulsed UVA laser has been shown in preliminary studies to eradicate much of the fungus and often clearing is seen in 9 to 12 months. This therapy is not widely available, but has been shown to be around 80% effective in these early studies. The FDA is still reviewing the Patholase laser application for approval, but the treatment is available in limited areas as an “off-label” usage. The laser light is painless and only affects the infected tissue. Hope abounds!
Funky looking toenails can also occur from psoriasis, eczema and other nail pathologies. If you have thick, nasty looking toenails, a visit to your local podiatrist for a PAS (Periodic acid-Schiff) stain of a piece of your toenail will determine if you have a fungal infection. If you have a positive PAS stain, look into the new laser therapy before your toenails cause a lifestyle change! There is hope even if you have suffered from embarrassing toenails for years!
Onychomycosis, over a period of time, makes your nails yellow, thick and often extremely disfigured. This is embarrassing and many people hide their toes in closed in shoes due to the disfigurement. Many people will even wear sneakers to the beach to avoid showing their toenails. Surveys have shown a lack of intimacy, decreased feelings of self-worth and depression associated with onychomycosis. With almost 30% of the adult population suffering from toenail fungus, and this number increasing to almost 90% in the elderly, why do most people feel it is just cosmetic? Because it hasn’t happened to them yet!
There is hope for people who suffer from toenail fungus. Traditional topical and oral therapies have been less successful than patient expectations. Lots of unhappy people with sever frustration!
Topical therapies patients have tried encompass a wide variety of products and folklore including the use of Vick’s Vaporub, organic cornmeal soaks, and a variety of over-the-counter products. Even the only FDA approved prescription topical, ciclopirox, is shown to be only 8% effective in their own package insert! Imagine painting your toenail with a topical therapy for over a year, every day, and still having ugly toenails!
After failure of topical therapy, most people discuss oral anti-fungals with their doctors. Common oral therapies include terbinafine, fluconazole, and itraconazole. These are more effective than any topical, but come with possible side effects including many drug interactions and liver problems. They are touted as somewhere between 50 and 70% effective depending on dosage and duration of therapy. Many people after taking these medications still have ugly toenails! More frustration!
Hope has recently increased for patients who have struggled with chronic onychomycosis. New laser therapy for onychomycosis is the most exciting treatment now available. A pulsed UVA laser has been shown in preliminary studies to eradicate much of the fungus and often clearing is seen in 9 to 12 months. This therapy is not widely available, but has been shown to be around 80% effective in these early studies. The FDA is still reviewing the Patholase laser application for approval, but the treatment is available in limited areas as an “off-label” usage. The laser light is painless and only affects the infected tissue. Hope abounds!
Funky looking toenails can also occur from psoriasis, eczema and other nail pathologies. If you have thick, nasty looking toenails, a visit to your local podiatrist for a PAS (Periodic acid-Schiff) stain of a piece of your toenail will determine if you have a fungal infection. If you have a positive PAS stain, look into the new laser therapy before your toenails cause a lifestyle change! There is hope even if you have suffered from embarrassing toenails for years!
Wednesday, May 13, 2009
Pregnancy and Your Achy Feet
I'm Pregnant.. My belly is getting bigger, I expected that. What I didnt expect was the swollen feet, the burning arch pain and the change in shoe size.
Did you know that during pregnancy your foot size increases at least a half size per pregnancy and is usually permanent after the 2nd one. Some women would be happy with that, an excuse to buy new shoes.. The problem is that most women dont realize that there shoes are to small. Measure your feet once a month and every time you buy shoes! You would be surprised by the changes in your feet.
Buying new shoes.. an easy fix.. But what about all the pain in my feet, and why are they so achy and tired. I have never had a foot problem before...
As your waist line expands, the weight gain can actually cause a change in your posture. The change in posture can cause you to walk differently.... which leads to abnormal stress on your back, knees, and feet. Your body is not used to this stress and will respond with pain, tenderness and overall discomfort.
The most common complaints that I see in my pregnant patients are: swollen feet, over pronation( foot flattening out like a pancake), arch pain, arch fatigue, heel pain, ingrown toenails and cramping of the feet and legs.
There are some easy fixes to make you a little more comfortable during this wonderful time of pregnancy. Make sure your shoes are the right size.. this will help prevent ingrown toenails, always wear supportive shoes, and never go barefoot. Maternity compression stockings are a good way to prevent swollen feet. Make sure you are stretching your legs and feet, always stretch before any type of exercise and make sure you are taking your prenatal vitamins.
Did you know that during pregnancy your foot size increases at least a half size per pregnancy and is usually permanent after the 2nd one. Some women would be happy with that, an excuse to buy new shoes.. The problem is that most women dont realize that there shoes are to small. Measure your feet once a month and every time you buy shoes! You would be surprised by the changes in your feet.
Buying new shoes.. an easy fix.. But what about all the pain in my feet, and why are they so achy and tired. I have never had a foot problem before...
As your waist line expands, the weight gain can actually cause a change in your posture. The change in posture can cause you to walk differently.... which leads to abnormal stress on your back, knees, and feet. Your body is not used to this stress and will respond with pain, tenderness and overall discomfort.
The most common complaints that I see in my pregnant patients are: swollen feet, over pronation( foot flattening out like a pancake), arch pain, arch fatigue, heel pain, ingrown toenails and cramping of the feet and legs.
There are some easy fixes to make you a little more comfortable during this wonderful time of pregnancy. Make sure your shoes are the right size.. this will help prevent ingrown toenails, always wear supportive shoes, and never go barefoot. Maternity compression stockings are a good way to prevent swollen feet. Make sure you are stretching your legs and feet, always stretch before any type of exercise and make sure you are taking your prenatal vitamins.
Thursday, April 30, 2009
The $2,000 Rusty Nail!
It all started with a late Saturday afternoon phone call. My hairdresser, Anne, called to ask if I could possibly look at her foot. Now! It seems that she and her daughter were in a creative mood while doing yard work that afternoon. They decided to rip up an old deck and make a new flower bed. Unfortunately, that old deck had a lot of ancient rotted wood held together with rusty nails. Anne was unlucky enough to have stepped on one of those rusty nails and had it stuck in her foot. Her daughter removed the board with the nail, but now, just a few hours later, Anne was quite concerned with the way her foot looked. She had cleansed the area with peroxide and put some ointment on it; but now her foot was red and swollen. Help!
Anne came over to my house so I could look at her foot. She had a typical puncture wound on the bottom of her foot with redness surrounding the wound and lots of drainage. It definitely looked like she may still have part of the nail and even maybe part of her shoe still in her foot. Infection was setting in! Off to the ER she went for x-rays and I scheduled an operating room to clean out the wound.
Her x-rays showed at least 50 small pieces of metal still in her foot. After I performed surgery to clean the wound, spending an hour taking small pieces of rust and metal shavings, as well a piece of sock and shoe out of her foot; Anne’s foot was on it’s way to recovery. Unfortunately, her wallet was $2,000 lighter after paying her deductible. So much for saving money by doing your own yard work!
What have we learned from Anne’s story? Hire yard workers? No, a better lesson is to address puncture wounds immediately! They are often much more contaminated than they look. Puncture wounds are extremely common in the foot. Even though they are extremely common, most people do not treat them adequately. Getting proper treatment within 24 hours is important in decreasing the infections that lead to serious complications.
Foreign bodies embedded in a puncture wound are extremely common. All kinds of things like toothpicks, glass, small pebbles, needles, nails and even wiry pet hair can become stuck in a puncture wound. Even pieces of your own skin, sock and shoe as well as dirt and foliage can be contaminating a puncture wound. Remember that all puncture wounds are considered dirty wounds because they involve penetration of the skin with a non-sterile object. Regardless of the foreign body, anything that remains in a wound can become an abscess and lead to a severe infection.
Treatment of puncture wounds should begin within 24 hours of the wound and start with cleansing of the wound and close monitoring until it is healed. Surgical cleaning with removal of any foreign bodies is often necessary coupled with a week or two of antibiotics, depending on the wound contamination. X-rays may even be needed to evaluate the bone structure for any involvement. A bonus is that metallic foreign bodies can also be detected by x-ray.
Often foreign bodies can be missed in the emergency room, so proper follow up with your podiatrist is important. Infection is a common complication, so your doctor will monitor your wound closely until it heals. Any changes, swelling, redness or discharge should be reported immediately. In diabetics or patients with poor circulation, a puncture wound can lead to an infection so serious that it leads to an amputation. Do not delay treatment! Hindsight is always 20/20, but you don’t want to be the one wishing they had come into the office when they are in the hospital with a severe infection.
Do not play around with puncture wounds, seek medical attention immediately!
Anne came over to my house so I could look at her foot. She had a typical puncture wound on the bottom of her foot with redness surrounding the wound and lots of drainage. It definitely looked like she may still have part of the nail and even maybe part of her shoe still in her foot. Infection was setting in! Off to the ER she went for x-rays and I scheduled an operating room to clean out the wound.
Her x-rays showed at least 50 small pieces of metal still in her foot. After I performed surgery to clean the wound, spending an hour taking small pieces of rust and metal shavings, as well a piece of sock and shoe out of her foot; Anne’s foot was on it’s way to recovery. Unfortunately, her wallet was $2,000 lighter after paying her deductible. So much for saving money by doing your own yard work!
What have we learned from Anne’s story? Hire yard workers? No, a better lesson is to address puncture wounds immediately! They are often much more contaminated than they look. Puncture wounds are extremely common in the foot. Even though they are extremely common, most people do not treat them adequately. Getting proper treatment within 24 hours is important in decreasing the infections that lead to serious complications.
Foreign bodies embedded in a puncture wound are extremely common. All kinds of things like toothpicks, glass, small pebbles, needles, nails and even wiry pet hair can become stuck in a puncture wound. Even pieces of your own skin, sock and shoe as well as dirt and foliage can be contaminating a puncture wound. Remember that all puncture wounds are considered dirty wounds because they involve penetration of the skin with a non-sterile object. Regardless of the foreign body, anything that remains in a wound can become an abscess and lead to a severe infection.
Treatment of puncture wounds should begin within 24 hours of the wound and start with cleansing of the wound and close monitoring until it is healed. Surgical cleaning with removal of any foreign bodies is often necessary coupled with a week or two of antibiotics, depending on the wound contamination. X-rays may even be needed to evaluate the bone structure for any involvement. A bonus is that metallic foreign bodies can also be detected by x-ray.
Often foreign bodies can be missed in the emergency room, so proper follow up with your podiatrist is important. Infection is a common complication, so your doctor will monitor your wound closely until it heals. Any changes, swelling, redness or discharge should be reported immediately. In diabetics or patients with poor circulation, a puncture wound can lead to an infection so serious that it leads to an amputation. Do not delay treatment! Hindsight is always 20/20, but you don’t want to be the one wishing they had come into the office when they are in the hospital with a severe infection.
Do not play around with puncture wounds, seek medical attention immediately!
Tuesday, April 21, 2009
Bunion Surgery Revealed!
Many patients are very apprehensive about bunion surgery. They have heard horror stories of severe pain and bad outcomes. These are usually not true. Bunion surgery is actually quite successful, in the right patient, done by the right doctor. Most patients have a lot of questions about whether they should have surgery and what to expect during and after surgery. This is an attempt to dispel old wive's tales and help you to make a more informed decision about bunion surgery. It is important to remember that every patient is different and this information is just to help you prepare to discuss your surgery with your doctor.
Who should do your surgery? Podiatrist versus orthopedic surgeon? A board-certified podiatric foot and ankle surgeon usually has much more experience in bunion surgery than the average orthopedic surgeon. Make sure your surgeon, no matter what their credentials (MD, DO, DPM), has passed their board certification and has experience in your type of surgery.
Who should consider bunion surgery? If your foot hurts every day, in every pair of shoes, and you have failed conservative treatment which should include: wider shoes, anti-inflammatories, padding, orthotics, and possibly steroid injection; you are a candidate for bunion surgery.
Bunion surgery involves an incision along the top of the big toe joint and the removal and realignment of soft tissue and bone to restore normal joint alignment and to relieve pain. The first metatarsal bone is often cut, realigned and then stabilized with small screws. There are no guarantees that a bunion surgery will fully relieve your pain because of wear and tear arthritic change to the joint and nerve damage from the deformity. Most patients achieve at least 85% relief of their symptoms.
Anesthesia selection is really patient and procedure specific, but light to moderate sedation, to make you sleepy, coupled with a local anesthetic block, similar to the dentist, is often used during the procedure. Some people do require general anesthesia due to a history of local anesthetic complications or other medical problems.
The procedure usually takes a little more than an hour, depending on the type of surgery. A more complicated bunionectomy can take two hours or more.
Bunion surgeries are usually done on an outpatient basis at a free standing surgery center or outpatient center at a hospital.
The most common types of bunion surgery are:
1. Keller: Removal of part of the metatarsal head (the part of the foot that is bulging out) and the base of the proximal phalanx (removal of part of the toe joint). This procedure is called a Keller bunionectomy. These usually work well in an arthritic joint but do not allow for complete joint function after surgery. Usually these are used in the elderly.
2. Austin or Chevron: Realignment of the soft tissue ligaments around the big toe joint. Removal of the part of the metatarsal head (the bump). Then, the first metatarsal bone is cut in a V-fashion then moved laterally to realign the joint. The cut or osteotomy is then stabilized with a pin or two small screws. This is the most common procedure and is known as an Austin bunionectomy.
3. Lapidus: Realignment of the soft tissue ligaments around the big toe joint. Removal of the part of the metatarsal head (the bump). Then, removal of a wedge of bone from the base of the first metatarsal and the bone adjacent to it (the cuneiform) as well as the cartilage surface of the two bones. The first metatarsal cuneiform joint is then reshaped and stabilized with two large screws or a plate. This increases the stability of the area and decreases recurrence of a bunion deformity. This procedure is known as a Lapidus fusion and is usually performed in adolescents or adults with really flexible foot deformities.
4. Other Procedures: Fusion (arthrodesis) of the big toe joint or Total Joint Implant (arthroplasty) are also common, but usually used when the joint is severely damaged and is not repairable.
The usual recovery period after bunion surgery is 8 weeks to 4 months, depending on the procedure and the health of the patient. Compliance also dictates how fast a patient heals. Swelling after surgery can last for up to a year.
In a Keller or Austin, the patient is usually completely off their feet for just a few days, then in a walking cast or special shoe for 4 to 8 weeks. Normal activity is usually resumed in 2 to 3 months.
In a Lapidus fusion, most patients are in a hard below knee cast completely non-weight bearing for 8 weeks, then a walking cast for 2 weeks, then a sneaker for another month. Normal activity is usually resumed in 4 months.
Every patient is different. Some patients have softer bone and require longer immobilization. Some patients require physical therapy after surgery.
There are risks involved in having any type of surgery. No matter how good your surgeon is, if you do not follow directions you may have a bad outcome. Scarring, prolonged swelling, a stiff joint, numbness, shortening of the big toe, degenerative arthritis, infection and continued pain are the most common complications. More serious complications can include non-healing of bone or a severe infection requiring a second surgery.
After having bunion surgery, most people are happy with the results. A survey by the American College of Foot and Ankle Surgeons revealed 95% of patients with good to excellent outcomes form their bunion surgery. After having surgery, your ability to walk and be active is likely to improve. The big toe joint is usually much less painful and functions better.
Some people are disappointed with their surgery results even though their joint looks and functions better. This is usually due to unrealistic expectations. You will still not be able to wear extremely high heeled shoes after surgery and it is unrealistic to think that your joint will be "perfect" or function like it never had a problem. With realistic expectation, most patients are happy with their bunion surgery.
Who should do your surgery? Podiatrist versus orthopedic surgeon? A board-certified podiatric foot and ankle surgeon usually has much more experience in bunion surgery than the average orthopedic surgeon. Make sure your surgeon, no matter what their credentials (MD, DO, DPM), has passed their board certification and has experience in your type of surgery.
Who should consider bunion surgery? If your foot hurts every day, in every pair of shoes, and you have failed conservative treatment which should include: wider shoes, anti-inflammatories, padding, orthotics, and possibly steroid injection; you are a candidate for bunion surgery.
Bunion surgery involves an incision along the top of the big toe joint and the removal and realignment of soft tissue and bone to restore normal joint alignment and to relieve pain. The first metatarsal bone is often cut, realigned and then stabilized with small screws. There are no guarantees that a bunion surgery will fully relieve your pain because of wear and tear arthritic change to the joint and nerve damage from the deformity. Most patients achieve at least 85% relief of their symptoms.
Anesthesia selection is really patient and procedure specific, but light to moderate sedation, to make you sleepy, coupled with a local anesthetic block, similar to the dentist, is often used during the procedure. Some people do require general anesthesia due to a history of local anesthetic complications or other medical problems.
The procedure usually takes a little more than an hour, depending on the type of surgery. A more complicated bunionectomy can take two hours or more.
Bunion surgeries are usually done on an outpatient basis at a free standing surgery center or outpatient center at a hospital.
The most common types of bunion surgery are:
1. Keller: Removal of part of the metatarsal head (the part of the foot that is bulging out) and the base of the proximal phalanx (removal of part of the toe joint). This procedure is called a Keller bunionectomy. These usually work well in an arthritic joint but do not allow for complete joint function after surgery. Usually these are used in the elderly.
2. Austin or Chevron: Realignment of the soft tissue ligaments around the big toe joint. Removal of the part of the metatarsal head (the bump). Then, the first metatarsal bone is cut in a V-fashion then moved laterally to realign the joint. The cut or osteotomy is then stabilized with a pin or two small screws. This is the most common procedure and is known as an Austin bunionectomy.
3. Lapidus: Realignment of the soft tissue ligaments around the big toe joint. Removal of the part of the metatarsal head (the bump). Then, removal of a wedge of bone from the base of the first metatarsal and the bone adjacent to it (the cuneiform) as well as the cartilage surface of the two bones. The first metatarsal cuneiform joint is then reshaped and stabilized with two large screws or a plate. This increases the stability of the area and decreases recurrence of a bunion deformity. This procedure is known as a Lapidus fusion and is usually performed in adolescents or adults with really flexible foot deformities.
4. Other Procedures: Fusion (arthrodesis) of the big toe joint or Total Joint Implant (arthroplasty) are also common, but usually used when the joint is severely damaged and is not repairable.
The usual recovery period after bunion surgery is 8 weeks to 4 months, depending on the procedure and the health of the patient. Compliance also dictates how fast a patient heals. Swelling after surgery can last for up to a year.
In a Keller or Austin, the patient is usually completely off their feet for just a few days, then in a walking cast or special shoe for 4 to 8 weeks. Normal activity is usually resumed in 2 to 3 months.
In a Lapidus fusion, most patients are in a hard below knee cast completely non-weight bearing for 8 weeks, then a walking cast for 2 weeks, then a sneaker for another month. Normal activity is usually resumed in 4 months.
Every patient is different. Some patients have softer bone and require longer immobilization. Some patients require physical therapy after surgery.
There are risks involved in having any type of surgery. No matter how good your surgeon is, if you do not follow directions you may have a bad outcome. Scarring, prolonged swelling, a stiff joint, numbness, shortening of the big toe, degenerative arthritis, infection and continued pain are the most common complications. More serious complications can include non-healing of bone or a severe infection requiring a second surgery.
After having bunion surgery, most people are happy with the results. A survey by the American College of Foot and Ankle Surgeons revealed 95% of patients with good to excellent outcomes form their bunion surgery. After having surgery, your ability to walk and be active is likely to improve. The big toe joint is usually much less painful and functions better.
Some people are disappointed with their surgery results even though their joint looks and functions better. This is usually due to unrealistic expectations. You will still not be able to wear extremely high heeled shoes after surgery and it is unrealistic to think that your joint will be "perfect" or function like it never had a problem. With realistic expectation, most patients are happy with their bunion surgery.
Tuesday, April 14, 2009
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