A War on Diabetes? Why Paula Deen is on Both Sides

It may not come as a surprise to find that Paula Deen has type 2 diabetes.  The woman who has made a career through a seemingly reckless approach to cooking and eating, using large quantities of cream, sugar, and butter in the majority of her recipes came out with the news earlier in January of this year.  What may come as a surprise to some is her latest paid position as a spokeswoman for Novo Nordisk, a company that makes Victoza, which is an injectable non-insulin diabetes drug. 

Yes, that is correct.  The woman who made a career of throwing caution to the wind, piling on the bacon and slathering on the mayonnaise is now promoting a diabetes drug.  The same woman that created the Brunch Burger, a hamburger that sits on a Krispy Kreme donut covered with bacon and a fried egg, revealed to the world on January 17^th what she and her doctor had known for close to three years.  She had type 2 diabetes, and now she would capitalize on it to create a name for herself in the diabetic drug market. 

With Deen’s approach to cooking, it was inevitable for her to develop some sort of health condition.  In this case it is type 2 diabetes, but obesity is also a  major risk factor for heart disease, certain types of cancer, gout, and a number of other diseases.  Virtually every system in the human body is effected by obesity.  Paula Deen’s recipes certainly did not take this into consideration. 

Deen’s announcement has sparked both support from her fans as well as sharp criticism from others.  The chicken-fried-everything chef turned diabetes spokeswoman has single-handedly created a talking point about obesity in America.  Her career moves reflect the attitudes of so many people.  On the one hand, she has contributed to obesity by promoting fat-laden recipes in gigantic portions.  At the same time, she has felt the effects firsthand with her diagnosis.  The difference, however, is that the business savvy Deen has made a profit on both sides. 

While it may not be surprising to find out that she has been diagnosed with type 2 diabetes, a disease for which obesity has been indicated as one of the greatest risk factors for developing, her next moves may be even more interesting.  She has gone on the record as doing almost nothing in terms of curbing her dietary behavior, stating that she has cut down on her consumption of sweet tea.  However, her name being branded on some of the most unhealthy menu items on the planet can not be erased.  

Central Florida Foot & Ankle Center, LLC 
101 6th Street N.W. 
Winter Haven, FL 33881 
Phone: 863-299-4551 
www.FLFootandAnkle.com

Cutaneous Larva Migrans

Cutaneous Larva Migrans is a tropical disease that is commonly found in the foot.  It is the result of an infection with one of a variety of hookworms, including the species Ancylostoma braziliense (cat hookworm) and Ancylostoma caninum (dog hookworm).  These parasites are typically seen in tropical or subtropical environments such as the Caribbean, Mexico, Brazil, Souteast Asia, and Africa.  Humans can pick these up as an accidental end-organism from walking barefoot on the beach, or in other areas of the body from contact. 

The skin lesions are extremely itchy, and can cause great discomfort for those affected.  The migrating line that is characteristic of the infection is caused by the path that the organism takes underneath the skin.  The parasite can actually be several centimeters ahead of the trailing line, as the reaction is delayed.  The lesion that forms is linear, typically in a winding pattern, red, and raised from the skin. 

Rarely, the lesions along the body may also contain small pustules.  These are formed from the parasite becoming trapped within the sebaceous glands.  Small, pimple-like lesions may occur.  This may complicate the condition, as these small lesions may erupt and become infected secondarily.  This complication, however, is rare.

Diagnosis of cutaneous larva migrans is made through clinical examination.  A history of travel to tropical or subtropical environments is common in those affected.  X-rays and other imaging studies are not necessary for the diagnosis.

The infection is self-limiting, as humans are only an accidental host for the parasite.  The hookworm will usually die with two weeks of infection. 

Treatment for cutaneous larva migrans is with oral ivermectin, an anthelmintic drug.  Treatment with a single dose is usually curative, and has rarely induced side effects.  Albendazole has also been used orally.  This drug is usually administered over three to five days, and has a similar curative rate as ivermectin.  Topical thiabendazole has also been used.  A biopsy of the skin one to two centimeters ahead of the lesion may reveal the parasite. 

 While it may seem like a creepy, crawly problem, the condition is ultimately benign.  In the vast majority of cases, cutaneous larva migrans resolves without complication, even without treatment.  If you find new lesions on your feet or any other part of your body that are painful or itchy, be sure to point them out to your doctor.   While cutaneous larva migrans may not be the most serious of diagnoses, this creepy problem may just make you want to wear sandals on your next vacation!

Central Florida Foot & Ankle Center, LLC 
101 6th Street N.W. 
Winter Haven, FL 33881 
863-299-4551 
www.FLFootandAnkle.com

Chronic Venous Insufficiency

Chronic Venous Insufficiency is the most common cause of leg swelling, affecting approximately 2% of the general population and up to 20% of the elderly population.  The condition affects about 2.5 million people in the U.S. alone. 

Symptoms of chronic venous insufficiency include swelling of both legs, with a feeling of “heaviness” being a common complaint.  An itchiness or constant dull pain is often reported, and symptoms will typically worsen through the day or after a long period of standing.  Skin changes are a common finding in chronic venous insufficiency, with the skin first changing to a darker color.  This is often associated with excessive dryness and flaking of the skin, known as stasis dermatitis.  As the condition progresses, the skin becomes thicker and taught, and becomes prone to breakdown or ulceration. 

The venous system is what is responsible for returning blood from the peripheral tissues back to the heart.  In the legs, gravity allows this blood to pool when the venous system fails in returning the blood.  This is most commonly due to faulty valves in the venous system. 

Normally, the deep venous system returns most of the blood back to the heart.  The superficial venous system shunts blood into the deep system, and valves in the veins connecting the two layers create a one way system.  When these valves fail, it allows for backflow in the venous system, causing pooling and chronic venous insufficiency.  The valves can be damaged from normal aging, blood clots, varicose veins, pregnancy, or injury to the legs or vascular system. 

The gradual development of swelling in both legs at the end of the day is suggestive of venous insufficiency when there is no other obvious cause.  However, the rapid development of swelling or swelling of one leg should be more alarming, and warrants the immediate attention of a doctor.  Some things that can cause swelling of the legs include cellulitis (infection), deep vein thrombosis (blood clot), tear of the calf muscles, ruptured Baker’s cyst, lymphedema, congestive heart failure, liver disease with cirrhosis, and damage to the kidneys.  Obviously some of these conditions are more serious and life threatening than others. 

Chronic venous insufficiency is largely a clinical diagnosis, meaning that advanced testing is usually not necessary.  However, some tests may be ordered to rule out other conditions when the diagnosis is not as clear.  An ultrasound study may be ordered to rule out a blood clot, or a deep vein thrombosis (DVT).  If there is an open wound, blood cultures and swabs of the wound may be taken to identify a possible infection.  Blood work may also be used to evaluate the function of the heart, liver, and kidneys if damage to these organs is suspected. 

Treatment of venous insufficiency depends on how advanced the swelling is.  In early cases, it may be treated with elevation of the legs when possible, walking programs, and light compression stockings. These modalities will help to return the blood to the heart, and prevent the progression of swelling. 

In more advanced cases, compression therapy may be taken on more aggressively, with heavier compression stockings or temporary wraps to bring the fluid out of the legs.  Unna boots are a soft type of cast that is often used for this reason.  Other modalities may include intermittent compression devices that actively squeeze the calf muscles, shunting blood back to the heart.  These machines can be used at home. 

Medications can be prescribed to help control excess fluid as well.  Diuretics, sometimes referred to as “water pills” can help a person to increase their kidney function, which in turn increases their excretion of fluids and urination.  This medications should be used with caution, and are most commonly monitored by the primary physician. 

Aggressive therapy of chronic venous insufficiency can help prevent the complications of the condition.  Most notably, these complications include ulceration and infection.  Ulcerations secondary to venous insufficiency typically begin with a minor traumatic event which opens up the skin.  At the incident, these injuries will usually bleed a disproportionately large amount.  Once the skin is opened, the pressure from fluid build up can cause the wound to expand in a circular pattern.  These wounds are usually found around the ankles, and will typically drain a great deal while they are open.  Venous wounds can be extremely difficult to heal, as the persistent swelling interferes with the normal healing process. 

Infection can persist in one of two ways in the presence of venous insufficiency.  Because of the tendency for people with venous insufficiency to ulcerate, an open wound is created.  This acts as a portal for infection into the body.  The skin changes seen with venous insufficiency also weaken the skin, and take away from its natural infection fighting ability.

Persons with swelling in their legs should be evaluated by a doctor to determine the cause.  Whether it is an immediate life threatening condition causing the swelling, or early signs of venous insufficiency, it should be treated aggressively and appropriately.  

Central Florida Foot & Ankle Center, LLC 
101 6th Street N.W. Winter Haven, FL 33881 
Phone: 863-299-4551 
www.FLFootandAnkle.com

Ankle Arthrodesis

Ankle arthritis can be an extremely debilitating condition.  Most commonly it is seen as a complication of ankle fracture or other ankle trauma, but it can also be seen secondary to inflammatory arthritis such as rheumatoid arthritis, infection of the ankle joint, Charcot neuroarthropathy, or tumors of the foot, ankle or leg. 

Ankle arthritis will present with significant pain with motion and with walking, and will typically limit the activities of those that suffer with the condition.  It is primarily a clinical diagnosis, with a history of a causative agent typically being related.  Physical examination will reveal an ankle joint with limited, painful range of motion, and pain on palpation to the joint.  X-rays are used to evaluate the extent of the arthritis in the ankle, and to monitor it’s progression.  Occasionally an MRI or CT scan may be ordered to rule out infection or intra-articular fracture, if there is a high index of suspicion clinically.  However, these advanced tests are not always ordered.

The ankle joint is actually a combination of three different articular surfaces.  There is an articulation between the talus and lateral malleolus, between the talus and the medial malleolus, and between the weight bearing surfaces of the talus and the tibia.  In significant arthritis, all three of these surfaces will be involved.  Arthritis will develop when there is damage to the cartilage, with a loss of joint space and growth of spikes of bone called osteophytes.

An important distinction must be made by the doctor in separating ankle arthritis from subtalar joint arthritis.  Subtalar joint pain can often feel to the patient as if the pain is coming from their ankle, when in fact it is coming from the joint below their ankle. This distinction can be made by injecting local anesthetic into the ankle joint in the clinic.  If 100% of the pain is relieved following the injection, then it is likely to be ankle arthritis.  If after injection there is still some pain left, then the subtalar joint can also be injected.  If this now relieves all of the pain, a combination of ankle and subtalar joint arthritis may exist.  There is often pain from the soft tissues surrounding the joints and from the tendons of the muscles that cross the ankle joint.  This is also a distinction that must be made clinically. 

Treatment of ankle joint arthritis begins with conservative therapy.  This may include treatments such as cortisone injections into the joint to relieve the pain, use of NSAIDs, orthotics, braces, physical therapy, and shoe modifications.  Sometimes a rocker bottom can be placed on the bottom of the shoe, which minimizes the motion at the ankle joint.  This can relieve pain in some individuals. 

When conservative therapy fails, surgery can become an option.  Most commonly, the ankle joint may be fused.  This is called ankle joint arthrodesis.  Ankle arthrodesis involves stripping the joint of its remaining cartilage, aligning the joint in an optimal position, and placing screws through the joint to hold it in place.  Holding the joint in place after the cartilage is removed allows the bones to heal to each other, thus eliminating the joint completely.  This means that there is no longer motion at the joint, as it is now one solid piece of bone.  Fusing the two bones together eliminates the motion, as well as the pain associated with motion at the joint.

A number of techniques for ankle arthrodesis have been employed, but generally there are two incisions made at either side of the ankle.  Through these incision the joint is reached, and the fusion can be performed.  After surgery, the patient will likely be placed in a splint or hard cast, and will remain in the cast for several weeks.  No weight can be placed on the operated foot for a minimum of 6 to 8 weeks while the bones are healing.  After this period of time, the patient will likely be transitioned to a surgical boot, which they may be allowed to walk in for 4 to 6 weeks.  Once the bones are completely healed and there is no longer an ankle joint left, the patient may be allowed to walk on their foot normally. 

There is often a deformity of the foot as well as the ankle, which can be addressed at the same time during surgery.  When the subtalar joint is involved in the pathology, it may be fused as well.  The elimination of motion at the arthritic joint is what decreases pain.  Many times with ankle arthritis there is inflammation and scar tissue build-up in the soft tissues around the joint, which can be removed at the time of surgery.  If there is damage to any of the tendons around the ankle joint, these can be repaired as well.

Of course, ankle arthrodesis is only performed when it is absolutely necessary.  It is a lengthy process of surgery and the post-operative course, and it is imperative that both the surgeon and patient prepare for this course. 

Central Florida Foot & Ankle Center, LLC
101 6th Street N.W. Winter Haven, FL 33881
Phone: 863-299-4551
FLFootandAnkle.com

Cheilectomy for Hallux Limitus

One of the most common conditions of the first metatarsophalangeal joint (MPJ) is a condition known as hallux limitus. This is defined as a less than normal range of motion of the joint. Normal range of motion is generally considered to be upwards of 65 degrees of dorsiflexion, with some references stating numbers even higher than that. Symptoms of hallux limitus may include achy, throbbing, or dull pain in the first metatarsophalangeal joint, exacerbated by activity. It may also cause compensatory changes in the other joints of the foot, which can lead to the development of pain or arthritis in adjacent joints. A palpable bump may be present on the top of the foot at the joint level, sometimes referred to as a dorsal bunion. When the range of motion is measured at less than 10 degrees of dorsiflexion, the condition may be called hallux rigidus.

Over the years, many investigators have postulated the causes of hallux limitus. Excessive length of the first metatarsal has been considered to be a causative factor in the past, which would theoretically decrease the amount of joint space at the first MPJ, thus limiting the motion at the joint. However, researchers have disproven this as a causative factor, and it may simply be an incidental finding.

Another biomechanical etiology of hallux limitus that has been cited in the literature is the presence of a hypermobile first ray and metatarsus primus elevatus. Hypermobility of the first ray means that the first ray, which consists of the hallux (big toe), the first metatarsal and the first cuneiform, is moving during the midstance and propulsive phases of the gait cycle. This erratic movement creates instability, which leads to jamming at the first MPJ, thus decreasing the range of motion available at the joint. Metatarsus primus elevatus is a related finding, which refers to a relative elevation of the first metatarsal on the rest of the foot, which would also decrease the amount of motion available.

Other causes of hallux limitus/rigidus that have come into question over the years include osteoarthritis, direct trauma to the joint, biomechanical malalignment such as hallux valgus, and various forms of inflammatory arthritis such as rheumatoid arthritis. Regardless of the cause of hallux limitus, however, the progression of the condition is rather predictable.

Typically the condition begins with a functional decrease in range of motion, characterized by a joint that has a decreased range of motion when weight-bearing. The progresses to a structural deformity with decreased range of motion in non-weight bearing situations, and the development of cartilage damage to the joint and eventually significant pain and disability. A number of authors have attempted to categorize this progression with classification systems, which take into account both the clinical picture and the radiographic analysis of the joint.

Perhaps the most widely used classification system used for describing hallux limitus is the Regnauld classification described in 1986. This classification system involves grades I-III, and helps to communicate the destruction and limitation involved. Grade I describes a first MPJ that shows a mild limitation of dorsiflexion with a mild dorsal bump, and early evidence of osteoarthritis apparent on x-ray. In grade II hallux limitus, there is evidence of more advanced arthritis development, as well as involvement of the sesamoids apparent on x-ray. There is a greater restriction in motion, and further narrowing of the joint space. Grade III describes severe limitation of motion, extensive development of osteoarthritis include significant osteophyte formation, and possibly loose bodies within the joint known as joint mice.

Conservative treatment should always be attempted before surgical intervention for hallux limitus. Only when conservative therapy has failed does surgery become an option. Conservative therapy may include the use of non-steroidal anti-inflammatory drugs (NSAID’s) in either oral or topical forms. Some doctors will use cortisone injections as well, while others prefer to avoid the use of injectable steroids due to side effects such as atrophy of skin and soft tissues and damage to the surrounding tissues. Orthotics are typically used as well, with a modification known as the Morton’s extension, which serves to protect and accommodate the first MPJ.

Once conservative treatment has failed, surgery may be an option explored by some patients along with the treating physician. A popular option for many foot and ankle surgeons is the cheilectomy. A cheilectomy is the removal of any osteophytes from the joint. Osteophytes develop as a part of cortical hypertrophy, which results from increased pressure through the bone from jamming of the joint. The cheilectomy serves to remove these redundant pieces of bone, which typically block the hallux from moving normally over the first metatarsal head. A cheilectomy will typically double the range of motion of the joint, and serves to alleviate pain as well.

A number of modifications exist for the cheilectomy, including how much to take off of the bone, or to peroform an osteotomy (bone cut) in the first metatarsal to create a larger joint space. Some surgeons will perform a cheilectomy at both ends of the joint, removing osteophytes from the proximal phalanx of the hallux if necessary. With or without these modifications, the cheilectomy has had good results reported for early stages of hallux limitus.

Central Florida Foot & Ankle Center, LLC

101 6th Street N.W.

Winter Haven, FL 33881

863-299-4551

www.FLFootandAnkle.com

Topaz Procedure for Plantar Fasciitis

One of the most common symptoms that a podiatrist will hear from their patients is that they are suffering from heel pain. This is often a chronic heel pain, that is unrelenting and not responsive to conservative treatment. Several things can cause this heel pain, including stress fractures of the calcaneus (heel bone), entrapment of a nerve running into the heel, or fractures of a heel spur. Most commonly, however, the complaint is related to plantar fasciitis.

Plantar fasciitis is a term used to describe a painful and inflamed plantar fascia, which is a thick, fibrous band of tissue running along the bottom of the foot. This band of tissue attaches to the calcaneus, which is typically where the pain is located. Pain is often worse in the morning with the first steps out of bed, or after long periods of rest, such as sitting at a desk. After the first few steps, the pain may decrease, but will get worse throughout the day with a lot of activity or standing. These are very typical symptoms of plantar fasciitis.

Because of its chronic nature, plantar fasciitis may also be referred to as plantar fasciosis, indicating the chronicity of the problem. When viewed under a microscope, the plantar fascia will show signs of degeneration and a lack of acute inflammatory cells, which is more consistent with a chronic tendinosis than with an acute inflammatory reaction. The plantar fascia will appear thickened as well. These findings all indicate that the condition is non-inflammatory, and is chronic in nature.

The exact etiology of plantar fasciitis has been the subject of debate for some time. Most evidence points towards increased traction at the calcaneus as being the cause of the pain. This increased traction has been associated with obesity, a difference in limb length, increased pronation of the foot, and many other things that increase the stress on the plantar fascia. Some believe that plantar fasciitis is partially due to periostitis of the calcaneus. The periosteum is a structure that surrounds bones and supplies blood to the bone. When this tissue becomes inflamed, regardless of the cause, it is termed periostitis.

Conservative therapy for plantar fasciitis revolves around trying to relieve the symptoms while at the same time decreasing the stress on the plantar fascia. This usually involves any combination of the following:

· Rest

· Ice

· Stretching

· Orthotics

· Physical Therapy

· Non-steroidal anti-inflammatory drugs (NSAIDs)

· Heel cups

· Night splints

· Taping

· Steroid Injections

· Advanced conservative therapies such as platelet-rich plasma injections and extracorporeal shockwave therapy

Generally speaking, conservative measures are exhausted before surgical intervention is attempted. Surgical intervention today typically involves releasing part of the plantar fascia to relieve the tension on the structure. For a long time, the only option surgically was to make a small incision into the foot and release the plantar fascia. With technological advances, new options have popped up.

One option that has become popular among foot and ankle surgeons over the past few years has been the use of Topaz to address plantar fasciitis. The Topaz procedure involves the use of radiofrequency microdebridement of the plantar fascia. The Topaz equipment is a small, pen-like device that delivers a small amount of radiofrequency to the tissues, which helps to remove some of the thickened, diseased tissue that results from chronic plantar fasciitis.

The device works by stimulating angiogenesis in the chronically diseased plantar fascia. This means that it stimulates the growth of new blood vessels. The formation of new blood vessels allows for inflammatory cells to reach the poorly vascularized plantar fascia. These inflammatory cells essentially “restart” the process from the beginning, allowing the tissues in the plantar fascia to reorganize and decrease the amount of scar tissue in the structure.

The Topaz procedure is designed to be as minimally invasive as possible. Generally, the plantar fascia can be microdebrided through small holes made in the skin with a small pin. The Topaz radiofrequency device can then be inserted into the small holes, and the plantar fascia can thus be reached without opening up the foot. These small holes created surgically are small enough to heal without the use of stitches. A small bandage can be placed onto the skin in the surgical area, and the patients can walk on the foot in a protective shoe within a few days.

Short-term and intermediate-term results of Topaz microdebridement for plantar fasciitis have shown good results, with a high percentage of success. Complications involved with open procedures are effectively eliminated from the post-operative course. Because of the avoidance of open surgery, Topaz is becoming a viable option among foot and ankle surgeons. The device has also gained acceptance for use in Achilles tendonitis.

Central Florida Foot & Ankle Center, LLC

101 6th Street N.W.

Winter Haven, FL 33881

863-299-4551

www.FLFootandAnkle.com

Tarsal Tunnel Syndrome

Tarsal Tunnel Syndrome is a condition of the foot and ankle in which the tibial nerve becomes entrapped along its course. The tibial nerve is a branch of the sciatic nerve, which begins in the distal one-third of the thigh, and courses through the back of the leg underneath the deep muscles. It courses slightly medially through the deep posterior compartment of leg muscles, and enters the foot through the tarsal tunnel. The tarsal tunnel is an organized strip of fascia that has separate canals for the arteries, nerves, veins, and muscles that pass through the area. The tibial nerve divides into three branches; the medial plantar nerve, the lateral plantar nerve, and the medial calcaneal nerve. These divisions are typically found proximal to the tarsal tunnel.

In tarsal tunnel syndrome, there is an entrapment of one or more of the branches of the nerve. The entrapment can be of the tibial nerve before it divides into the three branches, which may lead to more diffuse symptoms through the foot. Tibial nerve entrapment is one of the most common nerve entrapments of the foot and ankle, along with Morton’s Neuroma and an anterior entrapment of the superficial peroneal nerve.

The etiology of tarsal tunnel syndrome is most commonly attributed to repetitive microtrauma of the fascia surrounding the nerve, secondary to a hyper-pronation syndrome. The tissue becomes inflamed, which can entrap the nerve. There may also be varicosities of the posterior tibial veins which also pass through the tarsal tunnel, causing engorgement of the veins through the tunnel, leading to increased pressure on the tibial nerve. Other causes of tarsal tunnel syndrome include direct trauma to the nerve, systemic disease that effects the nerve or the surrounding components, a space-occupying lesion such as a benign tunor of the nerve or nerve sheath, and hypertrophy of the abductor hallucis muscle, which can put additional pressure on the nerve as it enters the foot.

Symptoms of tarsal tunnel syndrome include a burning or tingling sensation in the ball of the foot or the heel, as well as numbness or paresthesia. As the condition progresses, there may be some associated muscle weakness of the intrinsic muscles of the foot. Pain that travels towards the foot or up towards the leg is characteristic of tarsal tunnel syndrome.

Diagnosis is made with clinical symptoms as well as reproducing the symptoms by tapping along the course of the nerve. This may send reproducible pain travelling towards the toes (Tinnel’s sign) or upwards towards the leg (Valleix sign). The pain may also be reproduced by everting the foot in the clinic. Nerve conduction studies may be helpful in the diagnosis and in locating the exact area of impingement, but are not always necessary.

Conservative treatment of tarsal tunnel syndrome includes removing the force that recreates pain. This may involve limiting pronation of the foot through the use of orthotics. These may offer some relief, but will only work when in use. In the case of varicosities being the cause of the problem, some may find relief with the use of compression stockings.

Tarsal tunnel syndrome is more commonly dealt with surgically. A small incision is made in the medial side of the foot, and the nerve is identified. The entrapments of the nerve may be obvious to the surgeon performing the procedure, but in many cases the entrapments are not so apparent. The nerve is freed from any sites that may be entrapped. Most commonly the two sites that are released are the flexor retinaculum and the tarsal canal of the nerves. Additionally, the nerve may become entrapped under the soleus muscle’s retinaculum, the fascia of the abductor hallucis muscle, the intermuscular septum in the foot that the nerve courses under, and the medial band of the plantar fascia. These areas may additionally freed and left open. Post-operatively, a patient undergoing nerve decompression will be non-weight bearing for two-three weeks while the skin and deep tissues heal. During this time they will be able to freely move the foot and ankle when sitting or lying down, but will require an offloading boot when walking.

Tarsal tunnel syndrome can be associated with other conditions of the foot and ankle, and can often mimic other forms of heel pain such as plantar fasciitis. If you feel as though you are experiencing symptoms of tarsal tunnel syndrome, talk to your podiatrist. They will be able to investigate and diagnose the problem.

Central Florida Foot & Ankle Center, LLC

101 6th Street N.W.

Winter Haven, FL 33881

863-299-4551

www.FLFootandAnkle.com