Tailor's Bunion

Tailor's bunion is as an acquired lesion that causes chronic pain and swelling over the outer aspect of the distal foot. It is also known as a bunionette and is characterized by a painful prominence on the outer aspect of the foot in the area of the fifth metatarsal head.

These types of lesions were often seen on tailors with a cross-legged sitting posture. The posture resulted in pressure being placed on the lateral side of the foot.

Causes

Extrinsic causes - Commonly chronic

• Tailors' posture
• Footwear

Intrinsic causes

Structural Abnormalities

• Lateral bowing of the metatarsal shaft
• Enlargement of the metatarsal head
• Congenital splayfoot

Presentation

• Symptoms - Painful keratoses on the outer, bottom, or top aspect of the metatarsal head.

Imaging Studies

• Weight-bearing x rays of both feet
• Vascular studies are important with patients who have questionable circulation

Treatment

Conservative

• Padding
• Shoe modification
• Orthotic devices
• Anti-inflammatory medications
• Corticosteroid injections

Surgical Treatment

• Can be treated with simple removal of osseous bump when there is no evidence of anglular deformity
• With an angular deformity or a deviation in the bone is present an osteotomy (cut in the bone) is made and held together with a screw. The level of bone cut varies with the level of the deformity.

Possible Complications

• Malunion- Incomplete union or union in a faulty position
• Nonunion- A nonunion occurs when a broken bone does not heal
• Nerve Injury
• Joint pain and stiffness
• Symptomatic hardware
• Infection
• Recurrence

Diabetic Education

General Education for Diabetics:

Avoid any at home care for nails and calluses

Avoid constrictive bandages

Avoid open toed or opened back shoes

Be careful with adhesives and tape on the diabetic insensate foot

Buy shoes at the end of the day when the feet are the largest

Check the bath temperature before submerging the feet

Diabetics with impaired vision need someone to inspect there feet daily

Do not use chemical substances for removing corns or calluses

Dry the feet and between the toes thoroughly after showers

Inspect the feet and toes daily for any lesions

Inspect the shoes for objects before placing on feet

Never walk barefooted

Professional nail care at a podiatry office with regular visits

Protect the feet from sunburn

The use of a high toe box to accommodate hammertoes

The use of an insert to accommodate any lesions

The use of shoes with a wide toe box with extra depth

The use of water based lotion daily without moistening between the toes

Wear a shoe with an appropriate fit to avoid friction which can cause blisters

Gout

Gout is a common disorder of uric acid metabolism. It is a medical condition that usually presents with recurrent attacks of acute inflammatory arthritis. Gout is caused by cellular reaction to uric acid and can lead to deposits of monosodium urate crystals in soft tissues and joints.



Types

Primary gout - May occur alone. Accounts for about 90% of cases of the disease.

Secondary gout- May be associated with other medical conditions or medications. Accounts for about 10% of cases of the disease.


Frequency
Approximately 1% of the general population have gout.

Sex
Predominance- 90% male


Symptoms

Gout is associated with considerable pain.

Acute episodes of gout may incapacitate a patient.

Involved joints typically have the following symptoms: swelling, warmth, erythema, and tenderness.

The first metatarsal phalangeal joint is most commonly affected, however other joints can be involved such as the ankle or the knee.


A tophus deposit may develop in the ear.


Causes

Conditions that may cause acute changes in the level of uric acid and may precipitate a gout attack:

• Hyperuricemia
• End-stage renal disease
• Alcohol ingestion
• Disorders that cause high cell turnover with release of purines
• Over consumption of foods high in purines
• Underexcretion of uric acid - renal insufficiency

Long Term Effects

Untreated chronic tophaceous gout can lead to severe joint destruction.

Deposition of uric acid crystal in the kidneys may produce renal failure or obstruction.


Differential Diagnosis

Cellulitis- A severe inflammation of dermal and subcutaneous layers of the skin.

Gonococcal Arthritis- Is caused by infection with Neisseria gonorrhoeae.

Calcium Pyrophosphate Deposition Disease- Is a type of arthritis caused by the deposition of calcium pyrophosphate crystals.

Rheumatoid Arthritis- Is a chronic systemic inflammatory disease that affects the peripheral joints.

Psoriatic Arthritis- Is a chronic inflammatory arthritis that is commonly associated with psoriasis.


Laboratory Studies

Synovial fluid- The physician may aspirate the involved joint to rule out an infectious arthritis and to confirm a diagnosis of gout.

Serum uric acid.

Uric acid in 24-hour urine sample.


Imaging

Routine radiographs reveal punched-out erosions or lytic areas with overhanging edges. These finding are not acute.



Treatment

Acute gout

• Indomethacin- is the traditional Nonsteroidal anti-inflammatory drug (NSAID) of choice for acute gout.
• Colchicine.
• Corticosteroids- May be indicated in those patients who do not tolerate NSAID or Colchicine.

Chronic gout

• Probenecid- For patients who are hypoexcreters of uric acid.
• Allopurinol- For patients who are over producers of uric acid. Allopurinol reduces the generation of uric acid in the body.
• Uloric- Prevents uric acid production and lowers elevated serum uric acid levels.

Diet

Patients with gout should avoid beer and hard liquor. These elevate levels of uric acid and may precipitate attacks of gout.

High purine foods should be consumed in moderation:

• Kidney
• Liver
• Meats
• Shellfish

Tinea Pedis

Is a fungal infection of the skin that causes scaling, flaking, and itch of affected areas. It is also known as Ring Worm or Athlete's foot.

Symptoms
The symptoms of athlete's foot or tinea pedis typically include itching and burning of the feet.

The skin may peel or crack with or without any associated pain.

Commonly the rash is localized to the soles of the feet.

Sometimes the flaking skin may spread to the sides and tops of the feet in a moccasin distribution.


The digital interspases may have some moisture, peeling, redness and flaking as well.



Types of Tinea Pedis


T rubrum is the most common cause for tinea pedis.

Trichophyton mentagrophytes, and Epidermophyton floccosum are other causative organisms.




Vesicular tinea pedis-
Usually caused by T mentagrophytes.
This type is characterized by painful, pruritic vesicles most often on the instep.






Interdigital tinea pedis-Usually caused by T rubrum seen more in hot/ humid environments
This type is characterized by redness, maceration, fissuring, and scaling between toes. It is also associated with itching




Chronic hyperkeratotic tinea pedis-usually caused by T rubrum.
This type is characterized by chronic redness on the bottom of the foot or sides with scaling.




Risk Factors

• A hot, humid, tropical environment
• Prolonged use of footwear
• Hyperhydrosis- Sweating
• Certain people may have a genetic predisposition to the infection

Work Up

In suspected tinea pedis a KOH (potassium hydroxide) staining may be ordered by the doctor for fungal detection by obtaining a sample of the flaking skin

Fungal culture- may be performed to confirm the diagnosis of tinea pedis. A culture can be used to identify the fungal species.



Treatment

Tinea pedis can be treated with topical or oral antifungals. Some topical medications are over the counter. Topical agents are generally used for 1-6 weeks


Examples of Topical Medication

Topical Imidazoles

• Clotrimazole 1% (Lotrimin)
• Econazole 1% cream (Spectazole)
• Ketoconazole 1% cream (Nizoral)

Topical Pyridones

• Ciclopirox 1% cream (Loprox)

Topical Allylamines

• Naftifine 1% cream (Naftin)
• Terbinafine (Lamisil)

Oral Antifungals

Considered in patients with extensive chronic hyperkeratotic or inflammatory/vesicular tinea pedis

• Terbinafine (Lamisil)
• Itraconazole (Sporanox)

Prevention

• Keeping your feet clean and dry
• Avoiding prolonged moist environments
• Disinfecting old shoes
• Periodic use of anti fungal foot powder in the shoes

                                                         Learn more at http://www.shenandoahpodiatry.com/

Morton's Neuroma

Is a painful benign fibrotic enlargement of one of there common digital nerves. It is caused by a shearing force of the adjacent metatarsal bone. It most commonly affects the third common digital nerve. Morton's Neuroma is found to be more common in females. This may be related to the type of shoe gear often worn by females. It is most common in the 4th - 6th decade.


History

Obtaining an accurate history is important to making the diagnosis of Morton's neuroma.

Common Findings

• Pain in the forefoot and corresponding toes adjacent to the neuroma
• Pain is usually described as sharp and burning
• Pain may radiate proximal
• Numbness and tingling often is observed in the toes adjacent to the neuroma
• Intermittent pain
• Massage of the affected area may give some relief
• Narrow tight high-heeled shoes aggravate the symptoms
• Patients may feel as though they are walking on a wrinkle in there sock

Exam

• Firm squeezing of the metatarsal heads with one hand while applying direct pressure to the dorsal and plantar interspace with the other hand may elicit radiating pain.
• Mulder Sign - A silent palpable click produced by the lateral squeeze test. The neuroma moves between the metatarsals.
• Passive and active bending of the toe in an upward direction may aggravate symptoms.
• Sullivan's Sign - Toes adjacent to the affected interspace splay apart on weight bearing.

Imaging

• Ultrasonography
• MRI

Differential Diagnosis

• Stress fracture of the metatarsal
• Rheumatoid arthritis
• Hammertoe
• Metatarsalgia- plantar tenderness over the metatarsal head
• Neoplasms
• Metatarsal head osteonecrosis
• Freiburg osteochondrosis- characterized by interruption of the blood supply of a bone followed by localized bony necrosis.
• Ganglion cysts
• Intermetatarsal bursal fluid collections

Treatment

Treatment strategies for Morton's neuroma range from conservative to surgical management.


Conservative

Bio mechanical

• Orthotics

Medications

• Injections- Corticosteroid- Anti inflammatory agent
• Alcohol sclerosing- Causes a chemical neurolysis of the nerve and used as an alternative to surgery for Morton's neuroma
• NSAID's- Non Steroidal Anti Inflammatory such as Ibuprofen or Naprosyn
• Tricyclic Antidepressants- Amitriptyline(Elavil)
• Anticonvulsants- Neurontin (Gabapentin)
• Pregabalin (Lyrica)
• Duloxetine (Cymbalta)

Rehabilitation Program
Physical Therapy

• Cryotherapy-Cold Therapy- Cold may be applied using an ice bag or a cold pack
• Ultrasonography- Sound waves that are transferred to a specific body area via a round-headed probe. The sound waves travel deep into tissue, creating gentle heat. The heat helps relieve pain and inflammation
• Deep tissue massage
• Stretching exercises
• Phonophoresis- Has been used in an effort to enhance the absorption of topically applied analgesics and anti-inflammatory agents through the therapeutic application of ultrasound

Surgical Intervention

• Neurectomy- When conservative measures for Morton's neuroma are unsuccessful surgical excision may be beneficial

5 warning signs of foot problems in children

Foot pain in children is not something to be taken lightly or ignore. Sometimes it is hard for children to tell their parents when they are having foot troubles. Perhaps the child was born with a foot abnormality so their gait, though abnormal, seems normal to them. Or, a child may feel embarrassed about how their feet appear so they don’t want to bring it up. So, it is very important for parents to keep an eye on children's feet to keep them just as healthy as the rest of their body. Remember these feet have lots of miles ahead of them!!

Here are five things to look out for that might indicate your child is having foot pain or problems.

1. If your child is having trouble keeping up with other children~ If your child frequently lags behind other children in sports or other physical activities this could be due to flat feet causing the leg muscles to tire more easily. The muscles and feet become tired easier because the feet are not functioning as efficiently as they could be.

2. If your child suddenly stops wanting to participate in activities they enjoy~ If your child is suddenly not participating in their favorite activities this could be due to heel pain that is common in children ages 8-14. Heel pain can be caused by repetitive stress that occurs while playing sports. Too much strain can lead to pain and inflammation in the growth plate at the back of your child’s heel.

3. If your child is reluctant to show you their feet~ If a child notices a change in their feet they might be embarrassed or nervous that the change could lead to a trip to the doctors office. Start making it a habit early to check your children's feet for discoloration of the skin or nails, growths, calluses, redness, swelling or ingrown nails. Seek podiatric help for any of these signs of a problem.

4. If your child trips or falls often~ Although children are often clumsy while they are getting used to their body, repeated clumsiness can be a sign of in-toeing, balance problems or neuromuscular conditions.

5. If your child tells you they have foot pain~ Sometimes we get lucky and our children will tell us that their feet hurt. If this happens be thankful and take them to see a podiatrist right away. It is never normal for children to have foot pain and since they are growing all the time foot pain should not go overlooked. If injuries cause pain or swelling for more than a few days see a podiatrist asap.

Even if no symptoms are present and your children don’t complain of foot pain it is a good idea to get a yearly check up to make sure that the feet are growing properly.

Plantar Fasciitis

Plantar fasciitis is one of the most common problems treated in a foot and ankle practice.

Approximately 10% of the United States population experiences bouts of heel pain.

The plantar fascia acts like a windlass mechanism.

The plantar fascia is made up of 3 distinct parts: medial, central, and lateral bands.

It extends from the heel bone to the metatarsal heads.

The plantar fascia is a thick band of tissue in the arch of the foot.

Etiology

Biomechanical dysfunction of the foot is the most common origin of plantar fasciitis.

The pathology is believed to be secondary to the development of microtears in the fascia

There is an inflammation at the fascia at its origin due to repetitive strain of the arch with weight bearing.

Symptoms
Most common complaint is pain in the bottom of the heel. Patients will typically present with post–static dyskinesia. Pain with the first steps out of bed or periods of rest so it is usually worst in the morning and may improve throughout the day or with more activity.

By the end of the day the pain may be replaced by a dull aching that improves with rest.
Most people complain of increased heel pain after walking for long periods of time.
Generally the most common pain is that elicited upon palpation of the plantar-medial calcaneus

This is at the site of plantar fascial insertion to the heel bone. Pain can occur also at the central and sometimes at the lateral insertion as well.

A tight Achilles tendon can be an adjunctive finding and can contribute to the heel pain. This is known as an Equinus.

Diagnosis
Generally the diagnosis can be made with a good history.

X rays , MRI, and ultrasonography are important modalities to the diagnosis of plantar fasciitis.

X rays may reveal a plantar heel spur, which show the presence of abnormal stresses across the plantar fascia

A heel spur forms in a manner consistent with Wolff’s law. It should be noted that the heel spur is not the cause of the symptoms and therefore does not need specific treatment or removal.

MRI and ultrasonography shows the thickness of the fascia and helps rule out other problems that are not visible with x rays .

Treatment

Nonsurgical treatment include/ Conservative:

• Rest
• Icing
• Stretching
• Nonsteroidal anti-inflammatory medication such as Ibuprofen
• Taping/Strapping
• Orthoses (pre molded or custom-made)

• Physical Therapy
• Weight Loss
• Corticosteroid Injections
• Night Splints
  

These treatments should be used in combination.

Walking, running, and jumping sports are associated with plantar fasciitis; restriction of these activities may be necessary.

Surgical:

Severe cases may require surgical intervention if conservative therapy does not improve symptoms.

Extracorporeal shockwave therapy (ESWT) is an alternative treatment for chronic heel pain using acoustic-energy shockwaves

Plantar fascia release—performed by transecting part of the fascia - This is performed through an open incision or performed endoscopically

Another relatively new percutaneous technique is Topaz bipolar radiofrequency microdebridement, which applies a bipolar radiofrequency pulse to the plantar fascia.

Interview with Dr. Feeny

As some of you know, Dr. Feeny recently took her maternity leave from our office. Since she is a Podiatrist I thought it would be valuable to ask her some questions about her feet during her pregnancy and what advice she would give other pregnant women to help take care of their feet.

Hey Dr. Feeny, Thank you so much for letting me be nosey and ask you questions about your feet. First off, did you do anything at the beginning of your pregnancy to prepare for the changes and stress that would be put on your feet in the later months of your pregnancy?

I made sure that I wore supportive shoes throughout my pregnancy. Even if I got up in the middle of the night to go to the bathroom (and believe me that was often) I wore Birkenstock sandals.

At what month of your pregnancy did you notice your feet start hurting?

My feet really did not hurt due to these preventative measures.

That is so great to hear! How did your feet handle having to be on them for a large part of the day?

Well, my feet and ankles would become swollen during the day starting at about month 6. I started wearing compression stockings/support hose which helped.

Did your pregnancy affect your shoe size or the shoes you decided to wear?

I had a hard time tying my shoes that last month so I had to wear slip on shoes. Many women think that their shoes size changes due to weight gain but it is actually due to a hormone. This hormone causes the ligaments to stretch to aid in the childbirth. The ligaments in the feet also stretch which is why it is so important to wear supportive shoes.

Wow! That’s really amazing! I never knew that. So what did you do to ease the pain and symptoms you where experiencing?

I had my hubby rub my feet!! :)

Have you noticed any changes in your feet since you’ve given birth?

The swelling is gone and I can cut my own toenails again.

What advice would you give other pregnant women about taking care of their feet?

Make sure to wear supportive shoes, do not ignore small problems, and do not try to remove any ingrown toenails by yourself.

Thanks again for taking the time to share your experience. It has been really informative!

Mow the lawn, not your foot

The thousands of lawnmower-related foot injuries every year can be prevented

Springtime is here and weekend gardeners should note that their yards could become "toe-away" zones if they’re not careful when operating rotary-blade lawn mowers.

Each year, some 25,000 Americans sustain injuries from power mowers, according to the U.S. Consumer Products Safety Commission.

Although the number of accidents has steadily declined since the 1982 adoption of federal safety standards, we still see too many foot injuries from power lawnmowers. The blades whirl at 3,000 revolutions per minute and produce three times the kinetic energy of a .357 handgun. Yet we see patients who have been hurt while operating a mower barefoot! Foot injuries range from dirty, infection-prone lacerations to severed tendons to amputated toes.

If a mower accident occurs – with just a minor injury – immediate treatment is necessary to flush the wound thoroughly and apply antibiotics to prevent infection. Superficial wounds can be treated on an outpatient basis, but more serious injuries usually require surgical intervention to repair tendon damage, deep clean the wound and suture it. Tendons severed in lawnmower accidents generally can be re-attached surgically unless toes have been amputated.

Children under the age of 14 and adults over age 44 are more likely to be injured from mowers than others. Anyone who operates a power mower should follow a few simple precautions:
Don’t mow a wet lawn. Losing control from slipping on rain-soaked grass is the leading cause of foot injuries caused by power mowers.

• Wear heavy shoes or work boots when mowing – no sneakers or sandals.
• Mow slowly across slopes, never go up and down.
• Never pull a running mower backward.
• Keep the clip bag attached when operating a power mower to prevent projectile injuries.
• Use a mower with a release mechanism on the handle that automatically shuts it off when the hands let go.
• Always keep children away from the lawn when mowing it.

Dedicated To Your Healthy Feet,

Dr. Jennifer Feeny
For further information about foot and ankle problems, visit our website wwww.ShenandoahPodiatry.com

Women's Traveling Feet Feel The Pain

Researchers recently found a strong link between packing uncomfortable shoes and suffering foot pain while traveling. Young women are the most common victims of foot pain on the road. Not surprisingly, they are also the most likely to pack and wear uncomfortable, even dangerous shoes— high heels, flip flops, etc. —when traveling.

Eighty percent of the surveyed women under age 25 and 60% of surveyed women under 35 acknowledge that they sacrificed comfort for fashion on their last pleasure trip. While 60% of women, compared to 32 % of men, spent time planning their shoe selections for their trip, women were more likely than men to suffer foot discomfort related to poor shoe choices on their trips.

Switching shoes may not always be the best solution for correcting foot problems, but wearing appropriate footwear can prevent some problems from ever happening or alleviate others from continuing. As your foot care specialists, we can diagnose and recommend a course of treatment that may include a change in footwear, regular general care, medications, physical therapy, or orthotics. If your feet are tired of ill-fitting shoes, or if you are just tired of feet that hurt, we welcome your call at ShenandoahPodiatry.

P.S. Close to one-third of travelers admitted to packing either brand-new shoes, uncomfortable shoes, or both.