Friday, April 27, 2012

Keeping Kids Feet Happy

Foot and ankle problems in the child, much like many other ailments, can go unnoticed or undiagnosed for years.  The signs and symptoms can often be subtle and non-descript.  A child may not be able to explain what is wrong, and it may be up to the parents to recognize the symptoms.  Here are a few tips of what to look for.

·         Difficulty keeping up with the other kids may be a sign that something is wrong.  Often children with flatfeet have difficulty with sports and other activities due to early fatigue.  The muscles of the legs and feet can tire easily when they are not functioning properly. 
·         When a child withdraws from a sport or activity that they previously enjoyed, it may be due to pain.  Children will often not state explicitly that their feet hurt, but will rather shy away from sports.  Heel pain in a child between 8 and 14 years old may be caused by inflammation around the growth plate of the calcaneus, or heel bone.  This a treatable condition, and should not cause a child to give up something that they previously enjoyed.
·         If a child trips and falls often, it can indicate in-toeing, balance problems, or neuromuscular conditions.
·         A child not wanting to show you their feet may also be a sign that something is wrong.  Children are often scared of a trip to the doctor’s office, and if something is bothering them, they may not say anything for a while.  Ingrown toenails are notorious for going untreated long enough to become grossly infected in children.  Look for changes in the skin, hair and nails in a child, as well as any callus build-up.  These can be signs of a foot and/or ankle condition. 
·         Obviously, if a child complains of pain in their feet, ankles, or legs, it is a sign that something is wrong.  Particularly in young, otherwise healthy children, lower extremity pain should never be considered “normal”.  Children are not typically affected by the same types of overuse injuries in the adult, and thus should not be treated as adults. 

Most foot and ankle conditions in children can be treated conservatively, and very few will require surgery.  Often an orthotics or other non-surgical care is effective in relieving pain or other symptoms.  If your child exhibits any of these symptoms, they should be seen by a podiatrist for complete evaluation.  

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

Wednesday, March 21, 2012

Antibiotics – The End of an Era?

At a recent conference in Copenhagen on the topic of infectious disease, Margaret Chan, director of the World Health Organization, warned of the dangers of antibiotics resistance.  The problem is becoming so common, she stated, that it may trigger the “end of modern medicine as we know it”. 

Resistance to antibiotics occurs naturally, but the process is sped up as bacteria are exposed to antibiotics that they can survive.  This is exacerbated by improper use of antibiotics, over-prescribing for conditions like the common cold or the flu, and not following directions on the prescriptions.  The survival mechanism of the bacteria is to develop protection against antibiotics, thus creating antibiotic resistance. 

Antibiotic resistance has been sensationalized in the media as “Super Bugs”, most recently with MRSA becoming a household word.  MRSA, which stands for methicillin-resistant staphylococcus aureus, is a drug resistant bacteria that has become extremely common.  The bacteria that was once associated only with nosocomial infections is now found ubiquitously in the community setting. 

Chan discussed the “Post-antibiotic era” of medicine that may be approaching, stating that  "we are losing our first-line antimicrobials. Replacement treatments are more costly, more toxic, need much longer durations of treatment, and may require treatment in intensive care units.”

A number of strong, antibiotic resistant bacteria are already on the radar at most hospitals, with the infectious disease department at each hospital tracking what is common in their hospital, and which antibiotics are effective. 

One of the most commonly cited misuses of antibiotics is prescribing their use for sore throats associated with viral infections.  Because the virus causing the sore throat or cold is not affected by the antibiotics, it does nothing for the symptoms.  Furthermore, it can produce antibiotic-resistant microbes within the body, as they have now been exposed to the antibiotic. 

Podiatric physicians see the misuse of antibiotics in patients with ulcers and open wounds on their feet, ankles, and legs.  It is common practice for a physician unfamiliar with woundcare to prescribe antibiotics, even when the wound is uninfected.  However, this goes directly against the principles laid out by the Infectious Disease Society of America, in their guidelines for treating diabetic foot ulcers. 

The overuse and misuse of antibiotics is cited as the cause of antibiotics-resistant organisms, the practice of using antibiotics is difficult to get away from.  Antibiotics being manufactured today are stronger, and often more targeted towards certain organisms.  However, they can also cause more damage to the healthy tissues of the body, and that is what Chan and other doctors are so concerned with.

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

Friday, February 3, 2012

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 17th 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

Tuesday, December 20, 2011

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 

Monday, October 31, 2011

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

Monday, September 26, 2011

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

Thursday, July 14, 2011

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