Dark callus in a diabetic patient leads to amputation

I was consulted on a diabetic patient in the hospital last week who was admitted because of a foot infection. They did not know how or why the foot infection came about, only that there was a dark callus on the bottom of their foot for at least a month. They didn’t think anything of it until the foot became red and swollen, then within 24 hours there was significant drainage from the callus, redness that streaked up the leg, fever and flu-like symptoms. They also noticed their sugars running very high. This is what brought them to the emergency room. And it was this draining callus that caused me to amputate part of this patient’s foot the very next day. What was this dark callus and why did it have to end up with losing part of the foot?

With diabetes comes the loss of sensation called neuropathy. And with this comes the inability to feel increased pressure on the bottom of the foot. With this increased pressure to prominent areas, like the ones found under the big toe joint, comes callus formation. If the callus turns dark, that means there is enough pressure to the area to cause bleeding under the skin. This bleeding is what causes the callus to be dark. Any callus that goes unchecked in a diabetic patient with neuropathy can become soft underneath allowing the skin to breakdown and form an open hole called an ulcer. This can become infected, thus leading to possible amputation.

Let’s go back to the patient in the hospital. When I asked how long the callus had been there, the reply was uncertain, “maybe a month”. Daily foot inspection is the number one thing you can do as a diabetic, neuropathy or not, to save your feet. If this callus had been evaluated as soon as it was discovered, he would not have lost part of his foot.

When asked about their last podiatric foot check, the patient responded that they had never seen a podiatrist before, their regular doctor checks their feet every 3-6 months. The next step to saving your feet is to see a podiatrist on a regular basis. Although it is very important to see your primary care physician or endocrinologist (diabetic specialist) to keep your diabetes in control, it is equally important to see a podiatrist. The best thing you can do for your feet is be educated on how to save them. When I explained why I had to amputate part of the foot and how it all came about, the patient said, “If I had only known about that stuff, I would have seen you sooner”.

So why did I have to cut off part of this man’s foot? Once the soft skin under the callus starts to break down, it can become a liquid like goo of bacteria the becomes infected. With a very small opening or crack in the skin, more bacteria can enter thus setting the stage for a really bad infection. The problem is there is no where for this drainage to escape so it starts to eat away at the tissues next to it, working its way to the bone. Once the bone is full of bacteria, the best way to save the foot and usually the entire leg, is to remove the infected bone so it can no longer harbor bacteria. IV antibiotics will reduce the bacteria swimming in your blood stream from the infected foot and hopefully prevent even more bad things from happening.

Once he heals the surgery site, he will be able to walk like a normal person with a special insert inside his shoe. And now he is better educated and understands how important it is to check his feet every day and see me on a regular basis. If he sees anything that looks like a callus, he knows to call me right away. Very simple, but very important.

Getting back to normal after ankle sprains

You’ve sprained your ankle and it hurts. You’ve put ice on it and it still hurts. You are using crutches and it still hurts. You even wrapped it with an ace bandage. Now what? Ankle sprains are painful. And the worse the injury, the more the pain. But understanding how to rehab ankle sprains can greatly reduce the painful time and get you back in action sooner.

Most ankle sprains occur during sports activity when the foot is twisted on the leg. This causes the ligaments around the ankle to be stretched or torn, thus causing swelling, bruising and pain. Fracture of the ankle bones can occur as well.

First things first…stop your activity, rest and apply ice as soon as possible. Elevating the leg and wrapping the ankle with an Ace bandage will help control the swelling. If you cannot walk without significant pain, use crutches. Taking anti-inflammatories like aleve, advil or ibuprofen with help with swelling and pain. If your pain does not drastically improve over 2-3 days, a visit to your local podiatrist is next. If the sprain is severe, seek immediate treatment at a local emergency room.

So what are we looking for when you come in our office? First thing we want to know, “did you break a bone?”. If not, then our next step is getting that ankle moving as quickly as your pain tolerates to reduce instability of the ankle.

Rehabilitating an ankle sprain is the most important part of getting back to normal. This starts with home range of motion exercises, rest and wearing proper shoe gear. Notice I said nothing about returning to high heels or flip flops! Next, expect ankle pain to be present 3-6 weeks depending on severity, but this can be lessened by attending physical therapy.

Professional physical therapy services provide multiple modalities that can reduce your pain, increase your range of motion and increase your ankle stability, thus reducing your likelihood of another ankle sprain. Physical therapists can perform things like ultrasound, cold laser therapy, positional joint release and deep massage to help get you back to your old self again. Often ankles that have previously been sprained and require surgery several months later, did not properly rehab after the initial ankle sprain.

If you just injured your ankle, don’t wait months for it to get better. Start the rehab today. The physicians at Foot and Ankle Associates of North Texas are happy to help you in the process.

Plantar Fasciitis

“I work out and my heel hurts.” “I run and I am fine, it’s afterwards, my heel hurts.” “I stand all day at work and my heel hurts.”

Some of you may be familiar with the above statements. Some of you are looking for the quick fix, the magic stretch or device to make the “hurt” go away. I hear this a lot from customers and patients of the practice who visit me at the store. It is hard to see the look of despair particularly of runners who want to eliminate this “hurt” they cannot seem to control themselves. When a patient is diagnosed with Plantar Fasciitis from their Podiatrist, they are in a frantic search to make the pain go away fast. Rightfully so as they want to get back to life prior to the diagnosis.

So lets review exactly what this is and options on what to do once you have been told you in fact have good ole Plantar Fasciitis or also known as PF….

How do you say Plantar Fasciitis?
PLAN-tar fashee-EYE-tiss. It’s intriguing to hear from people their version however, this is the correct way to pronounce the words.

What does the Plantar Fascia do?
The plantar fascia is the thick ligamentous band in the bottom of the foot which is attached to the heel. The band runs forward and inserts into the ball of the foot. The plantar fascia encapsulates muscles in the bottom of the foot, however the main function is to support the arch of the foot by acting as a bowstring that connects the ball of the foot to the heel. This "support" enables us to propel ourselves forward more effectively.

Where exactly is the pain located?
Plantar fasciitis pain is found in the center or toward the inner side of the bottom of your heel. A lot of people notice the pain when they stand up after any period of rest especially after sleeping all night. After walking around for a bit, the pain can lessen or virtually disappear.

The interesting thing about this is PF is not caused by the heel striking the ground. PF is often referred to as heel spur syndrome however the spur is not the actual cause of pain. The spur is a sign the PF has been stressed for a period of time. Heel spurs are deposits of calcium in the plantar fascia where it attaches to the heel. You see, a spur is your body trying to respond to the injury and inflammation. So you really cannot blame the spur for causing the pain. It’s actually pretty common for people to have spurs and not have pain.

What caused my Plantar Fasciitis?
Common situations are:
An increase in activity. I.E. cutting grass in the spring on uneven ground and wearing improper footgear.
Biomechanical issues of the foot
A sudden injury
Wearing the wrong shoes
Weakened/Inflexible calf muscles
BEING OVERWEIGHT
Spending too much time on your feet
Or, quite frankly, it could be just one of those mysteries of life.

Notice the culprit listed in bold capitol letters above? Yep, your weight has a heck of a lot to do with PF. If you think about it, the foot must take on significant weight on a constant basis. Each step taken, the body weight is absorbed through both feet. The heel takes the brunt of the pressure. When the load is greater than what can be physically tolerated, damage starts and PF begins.

Does this mean fit people including star athletes cannot have PF? Absolutely not. Even football greats such as Eli Manning, quarterback of the New York Giants is in fact dealing with PF as I write this blog.We do however notice individuals who could be more fit for themselves often dealing with PF as opposed to those who control their weight.

So how do I fix it?
Here are a couple of thoughts on fixing PF....

You need to have your feet checked out by a Podiatrist to rule out if in fact you have PF or if there is another cause to your pain.

Wear the appropriate shoes. Don’t know what to wear – consult your local Certified Pedorthist.

If determined the appropriate shoe does not resolve the issue, orthotics are often utilized. Over the counter or custom orthotics may be helpful.

Physical Therapy – if recommended by your Podiatrist, PT can provide amazing results. The key with PT is you have to stick with the program!

Patience - Many people are frustrated when they are not seeing immediate results. As mentioned earlier, recovery takes time.

Finally, it all boils down to this...you need to follow your Podiatrist’s recommendations. No cheating here. PF can be controlled. You need to realize this simply does not go away overnight and it takes time. In some cases, surgical interventions are necessary after exhausting all other treatment avenues. If you truly want to get back to your routine whether it be walking or running or simply to stand up without heel pain, you need to follow the course of treatment which may include one or all of the above.

A note to the ladies….During treatment, your shoe fashion may result in quality athletic shoes. Future shoe options may require more focus than the cutest trends or the sale on the buy one get one teasers. It is a hard transition for some, but quite frankly, don’t you owe it to yourself and your feet?

Healthy Steps….for your feet….for your life!

What the Heck is a Sausage Toe?

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.

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.

So how does this really happen? Overuse is the most common mechanism of injury. Wearing flip flops or going barefoot on a regular basis. Starting a vigorous exercise program when you previously were not exercising. Walking a significant amount on a vacation like Disney World when this is unusual for your daily amount of activity.

Treatment starts with an evaluation and xrays to ensure you do not have anything else that may be causing your pain and to get a better idea of your bone and joint structure. Next, rest, ice and compression are the key to getting your swelling and pain under control. In severe cases, bracing may be necessary to achieve this goal. Once your pain and swelling have resolved, the next thing you need to do is prevent this from happening again. The best way to do that is wear good supportive shoe gear and be fitted for custom orthotics. Without preventative care, this tendonitis can because a chronic dysfunction of the foot and ankle requiring surgical reconstruction.

If you think you may have this condition, the physicians at Foot and Ankle Associates of North Texas are here to help!

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!

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.