Central Florida Foot & Ankle Center, LLC
101 6th Street N.W.
Winter Haven, FL 33881
When an ingrown toenail becomes infected, it is referred to as a paronychia. This happens due to the nail literally digging into the skin, causing a breakdown in the soft tissue, which allows bacteria to penetrate the natural skin barrier. The organism that is usually responsible for the infection is a staphylococcus species.
Paronychia will appear as a small, localized area of redness that may spread up the toe. It is generally quite painful, and there is usually a fair amount of pus and drainage from the site. In patients that are immunocompromised, such as diabetics or patients on long-term steroid regimens, a paronychia can advance to a more complicated infection of the soft tissues. These should be dealt with rapidly and aggressively by a doctor.
Treatment for paronychia includes incision and drainage of the infection site, which will help to relieve pain as well as remove much of the infection. A bandage is applied, usually with a topical antibiotic, and oral antibiotics may be used as well. Augmentin is a commonly prescribed oral antibiotic for paronychia, though it may not always be necessary. The bandage may be changed once or twice a day for the first few days, and soaks in a dilute betadine solution may be beneficial as well.
If ingrown toenails and paronychia are a chronic problem, they can be addressed with one of several more permanent procedures. A podiatrist will typically be the type of doctor that deals with this problem. After the infection resolves, a chemical matricectomy may be performed. This procedure involves using a chemical, such as phenol or sodium hydroxide, to permanently remove a portion or the entire nail matrix. The nail and nail matrix may also be surgically removed. Both are relatively minor procedures, and allow for a quick recovery. The recurrence of ingrown toenails after these surgical procedures is extremely low.
Generally speaking, a paronychia is a minor infection, and is treated as such. It is only in the diabetic or otherwise immunocompromised patient that it becomes an area of greater concern. If not dealt with rapidly, a minor infection can become a more serious, even life-threatening infection.
If you are experiencing pain from an ingrown toenail, show it to your doctor. Even if it is not infected, it should be dealt with in an appropriate manner, to relieve pain, prevent regrowth of the ingrown portion of the nail, and prevent a pending infection. With time, many ingrown toenails will ultimately become infected.
One of the most common complications of diabetes is the development of peripheral neuropathy. Along with the retina in the eye and the kidney, the nervous system is particularly vulnerable to unregulated glucose levels in the blood. This is because glucose, or free sugar in the blood, is able to freely move in and out of these cells without the use of glucose receptors.
Diabetic neuropathy comes in a variety of forms, depending on which nerves are involved. The sensory, motor, and autonomic (involuntary) nervous systems are all affected in diabetic neuropathy, but the sensory involvement is usually the first to become noticeably symptomatic. This often begins with a burning, tingling, or feeling of numbness in the feet. This may also occur in the hands at the same time. This pattern of distribution is commonly referred to as the “stocking-and-glove” distribution. Many theorize that the longest nerves are the first to be affected by peripheral neuropathy, hence the involvement of the hands and feet first. The pain is generally worse at night or at rest.
While the symptoms of numbness and pain of a burning or tingling nature may be uncomfortable, the later sequalae of peripheral neuropathy is certainly more of concern. Once the sensation in the feet is diminished or absent, the foot becomes prone to injury. This injury may go completely unnoticed, which can lead to an open, infected wound. Ulcerations secondary to diabetic peripheral neuropathy cause enormous amounts of morbidity, and can become complicated by systemic infections.
Signs of motor neuropathy in the diabetic patient include structural changes to the foot due to a loss of intrinsic musculature. This may include hammering of the digits, as well as a noticeable loss of the abductor hallucis, a muscle found on the inside (medial) of the foot near the arch. These changes may be more subtle than the subjective findings of pain due to sensory neuropathy.
Autonomic neuropathy also causes changes to the foot that can be appreciated on physical examination. Findings such as lack of hair growth to the digits, changes to the skin color or texture, changes in warmth, and decreased circulation to the foot can all be signs of autonomic neuropathy in the diabetic patient.
Unfortunately, there is no cure for diabetic neuropathy. The onset and progression of symptoms can be avoided by keeping tight control of blood glucose levels. Avoiding hyperglycemic events will prevent the nerves from being damaged by excessive glucose in the blood. In fact, many diabetics report an increase in pain after eating a carbohydrate-rich meal or if their glucose levels are running high.
Drugs that have been used to treat painful diabetic peripheral neuropathy are targeted at the symptoms rather than at the cause. This includes antidepressants such as amitryptiline or nortriptyline, gabapentin, topical capsaicin, and sedatives and pain relievers such as opiates.
A podiatrist will screen for neuropathy in diabetic patients. This is often a very simple, noninvasive test in the office where the protective sensation in the feet is tested. Further testing may be warranted for borderline cases, but is typically unnecessary. If you are diabetic and are concerned about peripheral neuropathy, have a discussion with your podiatrist or primary doctor today.
One of the most common conditions encountered by the podiatric physician is plantar fasciitis and other forms of heel pain that may present as plantar fasciitis. In fact, one study suggested that up to a third of all Americans will experience this form of heel pain at some point in their adult lives.
The plantar fascia describes a tough band of fibrous material found at the plantar surface of the foot. This structure allows for integrity of the foot, and helps to contain the deeper structures within the foot. It functions to assist in gait and maintain integrity of the musculature of the foot, and is therefore subjected to high levels of stress, particularly in the athlete or in the non-athlete that is on their feet for extended periods of time.
Plantar fasciitis is classically described as heel pain at the bottom of the foot, which may extend into the arch or even into the toes. It is a chronic inflammatory condition, which some suggest is more appropriately described as plantar fasciosis, which indicates the chronic nature of the condition, rather than an acute inflammatory process. Other causes of heel pain include stress fractures of the calcaneus, entrapment of the medial and/or lateral calcaneal nerves, tarsal tunnel syndrome, and certain forms of inflammatory arthritis. It is very possible and quite likely that some cases of heel pain may be multi-factorial, and have elements of more than one of these causes of heel pain.
Symptoms of plantar fasciitis include pain in the heel after long periods of rest, particularly in the morning. This is often referred to as “first-step pain”, and describes the sudden stretching of the plantar fascia band after it is allowed to contract some during rest. The pain may be relieved somewhat as the plantar fascia is “loosened”, but will return with increased activity.
Conservative therapy for plantar fasciitis revolves around exercise and stretching, corticosteroid injections, anti-inflammatory medications, icing, rest, and the use of orthotic devices. Newer advancements in technology have led to ultrasound and shockwave therapy, platelet-rich plasma therapy, and other high-tech therapies.
However, conservative therapy can often fail, and surgery becomes an option. Surgical management is traditionally performed as an open procedure, with a small incision made into the medial foot and a resection of some of the plantar fascia, or a simple release. Historically, the entire plantar fascia was commonly released. However, this was found to destabilize the lateral foot, and would lead to pain in this area. In fact, this complication was often more debilitating than the original plantar fascia pain. This realization led to a more judicious release of the plantar fascia, usually only involving the medial one-third of the structure. This led to much less instability and greater results.
Another historical approach to plantar heel pain was the resection of a bone spur on the calcaneus. For a long time it was believed that this was the source of the plantar fascia pain, and resection would lead to improvement. Research into “heel spurs” as the cause of heel pain would later disprove this as an etiology of the pain. Resection of heel spurs, or infracalcaneal exostoses, is not commonly performed as a result of this information.
With a greater understanding of plantar heel pain, as well as advancements in surgical technique and technologies, the use of endoscopic methods of plantar fascia release became a popular option in the 1990’s. With endoscopic plantar fasciotomy, one or two small incisions are made in the side of the foot, and a small camera is used to visualize this plantar fascia. Then, a specialized blade is inserted and the plantar fascia is released. This minimally invasive technique causes less damage to the surrounding tissues, and can lead to a faster recovery.
Post-operatively, however, a period of non-weight bearing or partial weight bearing is still recommended. With the initial development of endoscopic plantar fasciotomy, the idea of a faster recovery led to a quicker return to normal shoes. However, it was realized that this quick return to normal shoes led to increased instability and recurrence of pain. It is now recommended that the patient remain non-weight bearing in a surgical boot until healing occurs.
The endoscopic plantar fasciotomy remains a popular option for foot and ankle surgeons in the treatment of plantar fasciitis. Advancements since its initial inception make it easier to operate and lead to greater outcomes. Conservative therapy should be initiated and followed for some time before surgical intervention. If you are experiencing heel pain or symptoms of plantar fasciitis, consult your podiatrist for evaluation. Diagnosis can only be made after proper examination and evaluation.
A common cause of in-toeing in the pediatric patient is a foot deformity called metatarsus adductus. This is a condition in which the metatarsals, the bones in the foot that connect the toes to the midfoot, are pointed towards the direction of the midline of the body. Metatarsus adductus may be present on it’s own, or may be a component of a more extensive deformity, such as clubfoot. It’s incidence is approximately one in every one thousand live births, which is roughly ten times as common as clubfoot.
The exact cause of metatarsus adductus is not known, though there are several theories of how it develops. An increase in intrauterine pressure and a position in the womb that causes the feet to drift inward is the cause that is most commonly accepted. There also may be a familial pattern of metatarsus adductus, indicating that there may be genetic pre-disposition to the deformity. Conditions that cause an increase in ligament laxity, such as Ehlers-Danlos Syndrome, may also contribute to the development of metatarsus adductus.
The evaluation of metatarsus adductus typically involves clinical evaluation as well as x-rays of the foot to determine the position of the developing bones. Clinically, the toes will be pointed inwards towards the midline of the body. Sometimes only the great toe will be involved, in which case the condition is called metatarsus primus adductus. More commonly, however, all five digits are involved. The outside of the foot, or the lateral side, may show a prominent bump right in the middle of the foot. This is most likely the styloid process at the base of the fifth metatarsal, a very good indicator of metatarsus adductus. There also may be an increased gapping between the first and second toes when the child is standing, another classic finding.
X-rays will often reveal the extent of the deformity. The foot and ankle physician evaluating the patient will measure the angle that the forefoot points away from the midfoot and towards the middle of the body. The higher the angle, the more severe the deformity.
Important factors in determining the treatment of metatarsus adductus are the angle of deviation from the midfoot, the involvement of the midfoot and/or rearfoot in the deformity, and the reducibility of the deformity. Reducibility refers to whether or not the forefoot can be corrected with manipulation.
Conservative therapy is typically employed first, especially in children under the age of two years old. Most commonly conservative therapy involves manipulating the foot into a corrected position, and casting the foot so it stays that way. Depending on the degree of deformity, several rounds of casting may be used. This is referred to as serial casting. Besides casting, a splint such as a Ganley splint may be used as well as special shoes to prevent the deformity from recurring.
Surgical therapy is sometimes necessary to correct the deformity in the older child, or a child that has a more severe deformity. Surgical procedures involve both soft tissue and bone surgery, or a combination of both. Soft tissue procedures may include tendon releases and/or ligament release. These types of procedures will allow the foot to be manipulated more easily so that a corrected position can be attained. Bone work may involve taking small wedges of bone out of either the metatarsals or the midfoot in order to straighten out the foot.
After surgery, the patient is typically casted for a period of no less than 8-12 weeks in order to maintain the corrected position. Special shoes may still be required for some time to prevent the deformity from recurring.
There are a number of other musculoskeletal deformities that may be present in the lower extremity that lead to in-toeing. A thorough evaluation of the legs, knees, and hips is warranted in any child that has significant in-toeing. The incidence or torsional deformities of the tibia and femur is increased in the presence of metatarsus adductus, possibly due to the same reasons that the foot deformity develops in-utero. An increased incidence of hip dysplasia has also been reported by some authors, though other refute this correlation.
Thromboangiitis Obliterans is a rare disease that causes occlusion of the arteries in the hands and feet. It almost always affects men aged 20-40 with a history of cigarettes smoking or other tobacco use. It was first described by Von Winiwarter in 1879 in a patient with the affliction. It was later described by Leo Buerger, who documented and provided a full description of the disease. For this reason, it is commonly referred to as Buerger’s Disease.
The disease is caused by an inflammation of the blood vessels, particularly those of the hands and feet. When the vessels become totally occluded, a lack of blood flow to the affected area occurs. This can cause an immense amount of pain, and can lead to gangrene and ulcerations of the fingertips and/or toes.
In those with thromboangiitis obliterans, symptoms may include cold hands or feet, with the extremity appearing pale, red, or blue. Symptoms most commonly affect two or more extremities, but may also affect only one. There is usually pain in the affected limb, which may range from burning or tingling at rest to acute, severe pain. Symptoms are usually worsened by stress or cold. Thromboangiitis Obliterans is commonly seen in association with Raynaud’s Disease. The incidence is quite low, affecting approximately 6 in 10,000 people.
Treatment for thromboangiitis obliterans revolves around symptoms, as there is no cure for the disease. Increasing blood flow to the area may be achieved with vasodilators such as oral medications or nitroglycerin patches. Adding warmth and gently exercising the area can also increase blood flow.
Prevention of thromboangiitis obliterans is key to treatment. Quitting smoking and the use of tobacco products can prevent occlusions all together in many patients. Removing stress and avoiding the cold can also help.
The most serious complication of thromboangiitis obliterans is gangrene. The lack of blood flow to the hands and/or feet can cause the tissue to become gangrenous and die. If not cared for properly, this tissue can lead to serious infections, and possibly sepsis and death. Therefore, it is essential that thromboangiitis obliterans be cared for aggressively by the treating physician.
Chronic ankle sprains are a problem that plagues many individuals. Once the ligaments of the ankle have been compromised, they are subject to repeat injury. A person with chronic ankle sprains will often report an initial injury, possibly one that was never treated. There is usually constant swelling and pain at the ankle, and a feeling of instability, as if the ankle might give out at any time.
Chronic ankle instability can develop from damage to the nerve endings in the ligaments responsible for proprioception. Proprioception is the body’s ability to know where a particular part lies in space. Repetitive or chronic injury to the ankle ligaments can damage the proprioceptors in the ankle, leading to that feeling of instability. A person with chronic ankle injuries may also have attenuated, stretched out, and weakened ligaments, particularly of the lateral ankle.
Most commonly, the ligament that is damaged is the anterior talo-fibular ligament, or the ATFL. The calcaneofibular ligament (CFL) or posterior talo-fibular ligament (PTFL) may also be involved, as well as the extensor retinaculum, peroneal tendons, or the joints in the area such as the calcaneocuboid, tarso-metatarsal joints, subtalar joint, or the ankle joint itself. In high ankle sprains, the tibiofibular syndesmosis may also be injured.
Conservative care for chronic ankle injury revolves around protecting the ankle with high-top shoes or braces. These devices may work well in some individuals, but fail to offer enough support in others. In particular, high-performance athletes may be candidates for surgical repair of the ligaments if and when conservative therapy fails.
Surgery for lateral ankle instability focuses on reconstructing the lateral ankle and adding stability to the joint. There are a number of different techniques to do this. Most frequently, cases of chronic ankle instability are due to injury of the ATFL, or a combination of the ATFL and CFL. Depending on the extent of the injury, various procedures may serve to reconstruct and/or repair these ligaments.
Several procedures exist that use the peroneus brevis tendon, the extensor retinaculum, or both to reconstruct the ATFL and/or the CFL. These procedures may involve drilling a small hole in the tip of the fibula or the talus, and re-routing the tendon through the holes. When done correctly, this can add significant stability to the ankle joint.
Another technique involves using soft tissue from another part of the body, such as the tensor fascia lata in the hip and thigh, as a graft to reconstruct the ligaments. Cadaveric grafts or synthetic materials may also be used.
Many variables play into the decision-making of the surgeon and patient. The goals of the patient and the surgeon should be clearly communicated, as well as possible complications of the surgery and shortfalls that may exist. Lateral ankle reconstruction may not be an option for some patients, such as those with systemic conditions that may complicate the surgery or postpone healing. A thorough discussion should be had with a foot and ankle surgeon to assess the situation.
Gout is a form of arthritis, characterized by an acute onset of extreme pain. Gout attacks most commonly occur in the foot and ankle, in particular at the first metatarsophalangeal joint, the joint that connects the great toe to the foot. Gout also appears in the ankle, and can theoretically occur in any joint of the foot.
During an acute attack, the affected joint will appear red and swollen, and it will be hot to touch. It will also be extremely painful to touch. The simple touch of a bed sheet or even a slight breeze can cause an immense amount of pain. Evaluation by a doctor will be used to rule out other possibilities such as a fracture, infection, or other forms of arthritis. X-rays may be taken to visualize the effected joint as well. There are generally not any changes seen on x-ray with the first gout attack, but distinct changes may be seen with repetitive attacks. These changes include bony erosions seen around the joint, with the appearance of bone that has been chewed away. This is referred to as Martel’s sign.
An excess of uric acid in the body causes a gout attack. Uric acid is a byproduct of many foods; in particular it found in high quantity in red meats, lobster, and beer. Because of its association with overindulgence of rich foods, it has been historically referred to as “the disease of kings”. The high volume of uric acid crystallizes at the level of the joints, causing a tophus to form. The crystallization most commonly happens overnight. Some believe that this is due to a drop in body temperature, particularly in the feet, while sleeping.
A high level of uric acid in the body is a condition known as hyperuricemia. The excessive uric acid may come from several different sources. It may be dietary, as in the overconsumption of red meat, beer, and seafood. Hyperuricemia may also be associated with diabetes mellitus, hypertension, psoriasis, or congenital conditions such as Lesch-Nyhan syndrome. Excessive uric acid levels can also be caused by the use of some diuretics, particularly during their early use.
The treatment of gout is twofold; it must address both the acute painful phase as well as controlling the hyperuricemia. Initially, patients may be given colchicine or indomethacin to alleviate pain. After the acute attack has subsided, the underlying hyperuricemia may be addressed with allopurinol a drug that blocks the enzyme that creates uric acid in the body.
As the dog days of summer roll by, the heat index stays high while the training period continues. Whether you’re training for that fall marathon, or simply enjoy running outside, it is important to remain hydrated.
Depending on your type of workout, there are a number of options for hydration. Water is the obvious choice, but sports drinks are numerous and heavily marketed to the athlete and casual exerciser alike.
Most sports drinks have added carbohydrates and electrolytes to help with rehydration. The carbohydrates allow for added energy for your body as you are working out. The electrolytes sodium and potassium are added to help maintain fluid retention in the body, as well as key functions of muscles. For runners that are running for more than 30 minutes at a time, sports drinks are a good option to remain hydrated.
For longer distances, especially for those training for a marathon that may be running for several hours straight, there are more advanced sports drinks available. These drinks contain more complex carbohydrates that won’t breakdown as quickly, as well as protein for more sustained energy. They too have plenty of electrolytes to keep the athlete hydrated.
Enhanced and flavored waters offer vitamins and minerals in a sweetened package, but are usually not formulated for athletic hydration. They are, however, a good alternative to water for those with an aversion to the natural stuff. For workouts that last less than thirty minutes, water or an enhanced water are good choices.
A common mistake made by runners in the heat is to over-hydrate. Drinking too much water can make you sluggish and lethargic, and seriously slow down your pace. A good way to avoid this is to drink two cups of liquids two hours before exercising. This ensures that you are hydrated to begin with. Once the workout starts, it’s important to take sips of water/sports drink every fifteen minutes or so.
Ultrasound technology has been used for many years in the medical community, particularly for imaging studies. For the past fifty years or so, ultrasound imaging has been used extensively in obstetrics to view the fetus. This technology has given obstetricians the ability to diagnose congenital abnormalities that may pose a risk to the mother or the child, and to obtain the viability of the fetus. While many may be familiar with this application of ultrasound, few are familiar with the wide range of imaging studies that can be performed with ultrasound technology.
Ultrasound imaging, or sonography, has a particularly useful application in podiatry. The ability for ultrasound to be used to image soft tissues such as tendons, ligaments, and muscles makes it a valuable diagnostic tool. Some of the more common applications of ultrasound imaging in podiatry include imaging tendons and ligaments to diagnose ruptures and tears, evaluating the extent of plantar fasciitis, and evaluating soft tissue abnormalities such as ganglion cysts and neuromas.
The technology can also be used to help with injections, as it gives a clear picture of exactly what structures a doctor is injecting medications into. In some cases of plantar fasciitis, for example, a patient may benefit from an injection of cortisone into the area below the plantar fascia. Ultrasound imaging allows for a guided injection, so that the medication can be placed in exactly the right area to treat the problem.
Ultrasound works by sending out sound waves at a frequency that is inaudible to the human ear. These sound waves reflect off of the structures within the body, with different densities of tissue reflecting back different amounts of ultrasound waves. This allows for a differentiation of the structures, which is then converted into an image on the screen attached to the system. This technology is also used outside of medicine as SONAR technology, particularly in the sea when measuring the distance between two points.
Ultrasound has been shown to be a safe and effective tool in medicine. Because there is no ionizing radiation involved, such as that from X-rays or CT scans, it is considered to be a very safe test. It is also a relatively simple and quick test, which can be used to evaluate soft tissue disorders in the office. When comparing it to magnetic resonance imaging (MRI), it is much quicker, and also much less expensive. While it may not be able to produce the high quality images of an MRI, the use of ultrasound technology in evaluating soft tissues is clearly quite valuable.
Hallux limitus and hallux rigidus are two terms that are used to describe the progressive loss of motion that is seen in the first metatarsophalangeal joint. For normal function of the big toe, a range of motion of between 50 and 90 degrees is required. In hallux limitus, the range of motion is decreased. In hallux rigidus, there is little to no motion at all at the first metatarsophalangeal (MTP) joint.
The first MTP joint plays a critical role in normal gait. It is the area of greatest propulsion during the gait cycle, and plays a large role in balance. When the range of motion at the first MTP joint (located at the base of the big toe) is lost, significant secondary symptoms can occur, such as calluses across the bottoms of the feet.
Hallux limitus (and later, hallux rigidus) is a specific form of osteoarthritis localized to the first MTP joint. Therefore, the signs and symptoms are similar to that of common arthritis. This includes pain and stiffness in the joint when it is pushed upwards, such as when walking, running and squatting. Swelling and inflammation may be seen as well, particularly on the top of the foot around the joint. In particular, damp and cold weather may make the symptoms worse.
Later findings that are consistent with hallux rigidus include continuous pain in the joint, even when at rest. A person with hallux rigidus may have a visual bump on the top of their foot over the joint. This bump is actually a bone growth known as an osteophyte that can be seen on x-ray, and is common in osteoarthritis. Another common complaint is difficulty wearing shoes, particularly shoes that are tight in the toes, such as high heels.
When the joint becomes too painful to walk on, a limp may be apparent. The attempt to keep weight off the joint can lead to problems with other areas of the foot that are not meant to bear the weight that the big toe is designed for. Knee, hip, back and neck pain are also common conditions associated with hallux limitus and hallux rigidus.
Hallux limitus and hallux rigidus can be treated by either conservative or aggressive treatments, or a combination of both. Conservative treatment relies on stabilizing the foot, taking weight off of the big toe, and alleviating some of the pain associated with the condition. Stabilization of the foot is often achieved with a custom orthotic device or other form of padding. Symptoms may be alleviated with anti-inflammatory medications (NSAIDs), icing, rest, and padding.
More aggressive treatment is focused on the surgical management of hallux limitus/rigidus. The joint can commonly be fused, which takes away motion at the joint and alleviates the pain associated with the motion. Another option may be to use an implant, which can bring motion back to the joint. There are a number of different factors that go into the surgical decision making, so talk to your doctor about the options.
Hyperbaric oxygen chambers can be very useful tools in treating difficult-to-heal wounds. Ever wonder how they work?
In order to really understand what is happening in a hyperbaric oxygen chamber, you’ll have to understand a little bit of how oxygen is transported through the body.
All of the tissues in your body, from your skin to your muscles and bones, require oxygen. It’s easy to think of it as your body needing to breathe. In order to get oxygen to every tissue in your body, we must breathe in oxygen from the outside air into our lungs. This oxygen gets bound to hemoglobin, a protein found in the red blood cells. The red blood cells, now carrying oxygen, can transport that oxygen through the blood and to all of the tissues in your body.
Normal atmospheric pressure at sea level is measured as 1 atm. If we go up to the top of a mountain, the atmospheric pressure decreases; at the bottom of the ocean, the pressure will increase. At normal atmospheric pressure, it is only possible to transport a certain amount of oxygen through the body attached to hemoglobin.
If we increase the pressure at which we are breathing, however, it is possible to increase the amount of oxygen transported through the blood. In a hyperbaric oxygen chamber, the pressure is increased to 2 atm, or double the pressure at sea level. This allows for us to actually breathe in more oxygen than we would in the outside environment. The extra oxygen is actually dissolved into the plasma of the blood, making it possible to transport even more oxygen through the body. Before, we could only transport as much as the red blood cells could hold with hemoglobin.
Once there is an increase in oxygen in the blood due to it being dissolved into solution at higher pressures, the extra oxygen can drive the biochemical processes of wound healing. Different proteins in the body rely on oxygen to regenerate – if we increase the amount of oxygen available, we can increase the time it takes for the wounds to heal.
This idea of increased healing is especially important in patients with diabetes or peripheral vascular disease, two conditions that will slow the healing process.
Keep in mind that the only way to use hyperbaric oxygen is to breathe it in through the air. There are some products that are marketed as devices that will surround a wound with high-pressure oxygen, such as something that is wrapped around the leg. These products do not work in the same way, as none of the oxygen is actually being breathed in. In a true hyperbaric oxygen chamber, the patient will lie down completely enclosed in a tube.
With cold weather approaching, it’s important to learn how to protect yourself from the bite of cold! Whether you know it or not, your skin is the largest bodily organ and comprises 15% of your total body weight! Your skin works to protect your body from a host of environmental assaults, but trauma in the form of hot or cold injury can compromise its protective properties. A cold injury, such as frostbite can cause fluid loss within the skin and increase its breakdown and the likelihood of infection.
Although frostbite is used as a general term to cover all sorts of cold injuries, there are actually different and specific types of cold injury with frostbite being just one of them. The non-freezing types of cold injury are chilblains and immersion injury (trench foot). The freezing types of cold injury are frostnip, superficial frostbite and deep frostbite.
The mildest form of cold injury is called chilblains and is the most commonly experienced. It occurs when bare skin is exposed to temperatures of 33 – 60 Fahrenheit. The typical places for chilblains to occur are the ears, fingers and the tip of your nose. The best way to treat chilblains is prevention: avoiding the cold and protecting prone areas. Make sure to cover yourself adequately before going out! If chilblains do occur, the best way to treat it is via rapid rewarming and the application of moisturizers.
Immersion injury is also known as trench foot because in World War I, many soldiers who fought in the trenches experienced this type of cold injury. Unlike other cold injuries that are associated with cold air, immersion injury has to do with cold water. Cold water leads to much rapid heat loss than cold air by about 25-fold! As a result of the water penetrating the skin, trench foot can occur at much higher temperatures than the cold you may associate with frostbite. As a result of prolonged skin exposure to water in cold weather, your foot may look dusky and blue with swelling or blister formation. The best way to treat the affected area is to rewarm and dress the area with dry materials.
Winter time conjures up memories of snow angels, snowball fights and snow men! However, care must be taken to prevent cold injuries as a result of prolonged exposure to the weather. Skin injuries due to the cold are due to ice crystal formation in the tissue. To prevent crystal formation from occurring in the vital tissues of your body such as your brain and heart, blood gets diverted from your extremities (arms and legs) into the core (trunk and head). The process of redirecting blood flow to more vital structures is called arteriolar shunting.
The process of transferring blood to the inner most aspect of your body means that your extremities are more prone to dying off with increased exposure to cold. In essence, your body sacrifices your limbs in order to keep its vital functions going. Without blood keeping the area supplied with oxygen, nutrients and warmth – it is easy to see why areas furthest away from the head and heart are most affected by the cold.
Frostnip is a freezing type of cold injury where reversible ice crystal formation occurs. This is the mildest form of frostbite and the nose, ears and extremities are the most likely areas to encounter it. When frostnip occurs your affected areas will become white and have a decreased sensation. Rapid rewarming in water over the boiling point (104-108) is the best way to rescue those areas from further damage. The reasons for the use of very hot water is to shorten the frozen state, increase the local blood flow to the area and decrease the time cells are exposed to ions in the blood.
Extended exposure to the elements can turn a condition of frostnip into superficial frostbite! In this case, the cold has penetrated the area of skin and its underlying subcutaneous tissue. There are a variety of signs that indicate superficial frostbite has occurred: itching/burning that is lateral replaced by ache, swelling, cyanosis (blueness), excessive perspiration, and coldness of injured parts that occurs 2-3 weeks after the injury and lasts for many months! The cold did not kill off the nerves in the affected area so there is significant pain.
With winter time upon us, it is important to discuss safety measures and treatment tips if you should encounter a cold injury. Cold injuries can be likened to burn injuries in that the trauma caused to the skin is very similar. In addition, frostbite is graded in stages just like a burn injury.
Deep frostbite is the opposite temperature equivalent to a burn injury. Both burns and deep frostbite have degrees of severity and the greater the degree of burn, the more injury a particular area has sustained.
First degree and second degree cold injuries are actually classified as superficial frostbite whereas third degree and fourth degree injuries are of the deep frostbite category.
First degree frostbite is painful and the affected area looks white with delayed vascular supply to the area. Second degree frostbite leads to big blister formation, burning and tingling sensation, and the area will become hot and dry to touch. After rewarming the area, swelling and burning pain may occur and last for several days. Healing of the areas will occur after 3-4 weeks and pain relievers prescribed by your healthcare professional will help with the pain.
First and second degree frostbite occurs at the level of the skin and subcutaneous tissues. However, third and fourth degree frostbite (deep frostbite) involves skin and may extend to the bone!
Third degree burns are characterized by skin tissue death, blister formation, blue skin and excessive perspiration (hyperhidrosis). Throbbing/shooting pain will occur approximately 2 weeks after the injury due to nerve involvement. The fourth degree burns will involve tendon and bone with similar symptoms.
Despite healing, there will be no blood filling the affected areas with rewarming and as a result auto amputation of the area may occur. Auto amputation is basically complete tissue death and the body’s expulsion of that tissue or part! Treatment of deep frostbite requires physician supervision: rapid rewarming needs to occur and hospital admittance is the usual course of action.
With any cold injury to your lower extremity, it is important to consult with your podiatrist. They know the best way to evaluate the extent of injury and the resulting treatment. They will be able to prescribe you the appropriate medications to relieve your pain and help facilitate a recovery process. Remember that prevention is the best treatment so bundle up when you go outside into the cold this winter season!
Hammertoes are a common condition that is treated by podiatrists. When discussing hammertoes, it is important to discuss exactly which joints of the toes are affected, and how they are misaligned. The picture above depicts the three classic types of hammer digits, each of which has an effect on one or more of the three joints of the little toes on the foot.
In mallet toe, only the distal interphalangeal joint is affected. The interphalangeal joints are the joints within each toe. All of the toes besides the big toe have two interphalangeal joints. The big toe has one. Mallet toe is characterized by a toe that is straight until the last “knuckle” joint of the toe, where it is pointed downwards.
In claw toe, all three of the joints of the lesser digits are affected. The metatarsophalangeal joint, the joint that connects the toe to the forefoot, is deviated upwards, while the two interphalangeal joints are deviated downwards. This creates a claw-like appearance, as is seen in the bottom diagram of the drawing.
The most common form of hammer digits is depicted in the middle diagram. This is the classic form of hammertoes. In this form, the metatarsophalangeal joint is deviated upwards, the proximal interphalangeal joint (the one closer to the middle of the foot) is deviated downwards, and the distal interphalangeal joint (the one further down the toe) may be either normal or deviated slightly upwards.
Besides the aesthetic changes to the toes, hammertoes can be a source of pain for many people. When the joints of the toe are misaligned, it forces the toes to take up more space in a shoe. This can often lead to corns on the tops of the toes, as they are rubbing against the top of a shoe.
Additionally, hammertoes are often pointed towards each other, which cause the toes themselves to rub against the other toes. This can also cause corns and calluses to form, as well as abrasions in between the toes.
Hammertoes are caused by a loss of muscle stability and balance that is formed by the muscles of the foot. The flexors on the back of the leg and the extensors on the front of the leg serve to counterbalance each other on the toes, thereby keeping the toes straight. When the balance is lost from things like loss of function of one muscle or strengthening of another muscle, the toes can become deformed. This problem is often seen in women who wear high heeled shoes.
When treating hammertoes, claw toes, or mallet toes, a podiatrist may use one of two approaches. The conservative approach would be to treat the corns and calluses formed by the toes rubbing against either each other or the shoe. This may be done by burning or shaving off the dead skin causing the pain, as well as modifying the shoe gear to accommodate the misaligned toes.
The other route is to correct the misalignment of the toes through surgery. Several different methods are used depending on the extent of the deformity – only your surgeon will be able to decide which the proper method to use is.
The term “stress fracture” often gets thrown around a lot in medicine, but sometimes it is poorly understood. In order to understand how a stress fracture occurs and what exactly it is, a little bit of information on how the bones form is necessary first.
A common misconception is that bones are dead. This is one-hundred percent false. Bones are in fact a complex organ system. They are a living tissue that is constantly remodeling itself. Some cells in the bones work to degrade the bone material, while others work to rebuild it. This constant turnover of bone material is extremely important in bone health, and defects of this system are the cause of disease like osteoporosis. It takes approximately seven years for a complete turnover of the human skeleton – if you are twenty one years old, your bones have gone through three complete cycles!
When the repetitive stresses of activities like walking and running outpace the bones’ ability to repair themselves, a stress fracture occurs. Stress fractures are extremely common in runners, where the forces on the body and the bones are increased greatly. Stress fractures account for roughly 10% of all running injuries, and 95% of all stress fractures occur in the lower extremity.
A common thought among podiatrists and other types of sports medicine doctors is that stress fractures are more likely to occur during muscle fatigue. The muscles play a large role in distributing body weight and forces throughout the body. When the muscles are fatigued, this distribution is lost and more force is placed directly on the bones. The bones are therefore subjected to greater direct forces, and a stress fracture will often be the result. For this reason, there is a large correlation between fitness level and the occurrence of stress fractures. In other words, the more in shape you are, the better your muscles are at distributing the forces associated with running and other activities.
Women are often considered to be at a greater risk for stress fracture as well, particularly women with low levels of estrogen. Estrogen plays a role in reshaping the bone – if this mechanism is lost, the stresses of running and walking can often outpace the remodeling of the bone. Other factors involved in an increased risk of stress fracture include old, worn-out running shoes that have lost their shock absorbing capabilities, a difference in limb length, changes in running surfaces (such as moving from grass or a rubber track to cement) and differences in running style.
The symptoms of a stress fracture include tenderness over the area and pain upon activity. There may be some swelling in the area as well, though this is not as common. Your doctor will diagnose a stress fracture using these clinical signs as well as with an x-ray. Stress fractures are usually treated by reducing activity, and putting the effected leg in a non-weight bearing cast.