Tinea Pedis

Tinea pedis is a superficial infection of the feet with dermatophytes, a subset of fungus that lives off of the keratin in the skin. It is the most common fungal infection of the body, and is typically characterized by a burning, tingling, or stinging feeling in the feet and toes. Tinea pedis may also be referred to as athlete’s foot.

Tinea pedis is often broken down into four distinct entities. The first is chronic tinea pedis, which is most classically described as a silvery, scaly appearance of the bottoms of the feet, in a moccasin-like appearance. This means that the extent of the infection is diffusely spread across the entire plantar surface of the foot, and commonly expands up into the toes and the sides of the foot, where a moccasin may come in contact with the skin. The organism that most commonly causes this form of tinea pedis is trychophyton rubrum, or t. rubrum.

Another distinct form of tinea pedis is the vesiculobullous or acute vesicular form. This condition is most commonly caused by the organism trychophyton mentagrophytes (t. mentagrophytes). In addition to the burning, tingling, or stinging sensations associated with tinea pedis, the acute vesicular form will also show very small blisters, typically in the arch of the foot. This form of tinea pedis shows acute inflammation, and is often treated with a topical steroid as well as a fungicide.

Acute interdigital tinea pedis is also a common form caused by t. mentagrophytes, and is seen in between the toes, extending down onto the bottom of the feet towards the ball of the foot. This condition may or may not be inflammatory. When acute inflammation is present, a steroid/fungicide combination may also be used for treatment.

Acute interdigital tinea pedis may progress to the more serious but less common ulcerative tinea pedis. Ulcerative tinea pedis occurs when a case of untreated interdigital or vesicular tinea pedis causes severe breakdown of the skin, and a secondary bacterial infection ensues. This bacterial infection superimposed on a fungal infection can cause a great amount of skin loss on the bottoms of the feet, and can lead to a disabling condition. Treatment typically involves a fungicide/steroid combination as well as oral antibiotics.

With the exception of the more serious ulcerative form, most cases of tinea pedis are successfully treated with topical medications. Topical medications consist of a fungicide with or without a very low dose of steroid. The steroid is included in forms of tinea that include inflammation, and serves to decrease some of that inflammation. However, in cases without inflammation, a steroid should not be used so as to avoid the unnecessary side effects associated with steroids. In cases such as chronic tinea pedis, a plain fungicide will suffice.

Patients with severe inflammatory tinea pedis or a case that has not responded to topical treatment after at least one month may be considered for oral medications. Oral medications do come with inherent risks, in particular the risk of liver damage. Blood work is performed before oral anti-fungal medications are prescribed for tinea pedis and/or fungal nail infections.

Central Florida Foot & Ankle Center, LLC

101 6th Street N.W.

Winter Haven, FL 33881

Phone: 863-299-4551

www.FLFootandAnkle.com

Ganglion Cyst

A ganglion cyst is a soft tissue mass that is filled with a protein-rich fluid. They are walled off from the surrounding soft tissues with a thin wall, and may be single or multi-chambered. Ganglion cysts are most commonly found on the backs of the hands and wrists, or on the top of the foot and ankle. They can sometimes be worrisome to the patient when they develop, but it should be comforting to the patient to know that they are benign and usually harmless.

Ganglion cysts can develop in a variety of different tissues, including nerves, tendons, and joints. The exact mechanism of their development is not completely understood, but they are usually attributed to repetitive trauma. In the foot and ankle, an irritating shoe may be the cause.

The symptoms are dependent on which structures are affected and on the size of the growth. If nerves ate involved, there may be a bunring or tingling sensation, or the area may go numb. There is typically pain involved in any ganglion cyst, particularly when they grow in size and become irritated.

Historically, ganglion cysts used to be referred to as “bible bumps”. This is due to the fact that they used to be treated by slamming a large book, such as a bible, onto the back of someone’s hands with a ganglion cyst. Not surprisingly, this turns out to be a terrible treatment for ganglion cysts. It leads to a high rate of recurrence, and is probably quite painful.

Today, ganglion cysts are treated in a more precise manner. X-rays are typically taken as a first line diagnostic exam to rule out other pathological processes, such as invasive tumors, malignancy, and soft tissue calcifications. Ultrasound is becoming more popular as a diagnostic exam for ganglion cysts, as it is a quick, easy, and inexpensive method of visualizing the cyst beneath the skin. MRI may be used as well, but is more expensive, time consuming, and is generally reserved for surgical planning.

Treatment of a ganglion cyst usually begins with aspiration of the cyst with a small needle. Removing the fluid can relieve some of the pressure on the area, as well as serve as a definitive diagnosis. The area is typically numbed prior to aspiration, to provide comfort for the patient. A steroid is often injected into the area as well to reduce swelling and inflammation. Padding the area may also prove to be helpful in treatment, but is usually not sufficient on its own.

Some ganglion cysts may require surgical removal for complete relief. It should be noted, however, that the recurrence of ganglion cysts is very high in both surgical and non-surgical treatment.

Central Florida Foot & Ankle Center, LLC

101 6th Street N.W.

Winter Haven, FL 33881

Phone: 863-299-4551

www.FLFootandAnkle.com

Tarsal Coalition

A tarsal coalition is when two tarsal bones (the bones of the mid- and rear-foot) become fused. This can cause pain and a loss of motion at the effected joint, as well as other biomechanical symptoms.

The most common joint to be effected by a tarsal coalition is the subtalar joint, which is a joint formed by the articulation between the talus and the calcaneus. There are actually three facets between the two bones that help to form the joint – the anterior, middle, and posterior facets. Most commonly, a talocalcalcaneal coalition is formed between the middle facets. When a coalition exists between the talus and the calcaneus, it may present as a rigid flatfoot deformity with considerable decrease in range of motion.

Other tarsal coalitions that are occasionally seen include calcaneo-navicular and talo-navicular coalitions, though these are much less common than talocalcaneal coalitions. Overall, the incidence of tarsal coalitions is about 1% of the population. There is a familial inheritance that is often seen with tarsal coalition, though it is not thoroughly understood.

The cause of congenital tarsal coalition has been an area of interest for quite some time. It was first proposed in 1897 that they were caused by the incorporation of accessory bones within the joint, but was later postulated that the bones actually failed to separate in the fetus. The latter of the two explanations is the more commonly accepted situation.

Tarsal coalitions may also be acquired from trauma to the joint, degenerative changes to the joint such as what is seen in osteoarthritis, and fractures through the joint space.

Diagnosis of tarsal coalition comes from a combination of clinical findings, as well as x-ray, CT, and MRI imaging. Imaging techniques allow a doctor to visualize the joints to evaluate for fusion.

Clinical findings include pain, stiffness and decreased range of motion at the joint, rigid flatfoot deformity, and local tenderness and possibly swelling.

Conservative treatment is usually initiated once the diagnosis is made. This most commonly includes custom-made orthotic devices that prevent the effected joint from moving too much. The movement of the fused joint is what causes much of the pain. Immobilization may be required with an ankle brace or other device. Physical therapy can help in some cases, as well as shoe modifications to accommodate the coalition.

Surgical treatment can include either removal of the coalition or a fusion of the joint to prevent movement altogether. There are several different ways of performing each of these types of procedures, depending on the individual patient and situation.

Central Florida Foot & Ankle Center, LLC

101 6th Street N.W.

Winter Haven, FL 33881

Phone: 863-299-4551

www.FLFootandAnkle.com

Heel Spur vs. Plantar Fasciitis

The terms “heel spur” and “plantar fasciitis” can often be confused. The two diagnoses are unique from one another, but are related and are often seen together. It is helpful to understand the difference between the two, and to understand how they relate to each other.

Plantar fasciitis refers to a process that elicits pain in the bottom of the heel, along the bottom of the foot, and sometimes even into the toes. It is caused by excessive stress placed on the plantar aponeurosis, a thick piece of fibrous tissue that expands the length of the foot. The pain is most commonly seen at the origin of the plantar aponeurosis, or the plantar fascia, which is at the bottom of the calcaneus (heel bone).

The term plantar fasciitis is somewhat of a misnomer. The suffix “-itis” at the end of the word implies that there is inflammation in the plantar fascia. While this may be present in some cases, a majority of cases do not have any associated acute inflammation. Because of this, the term plantar fasciosis is probably a more appropriate term, which would refer to the condition as a chronic condition of pain. In scientific research, it is commonly referred to as plantar fasciosis.

A heel spur, on the other hand, is a piece of bone coming off of the bottom of the calcaneus. This is called an ostephyte. The cause of heel spurs is not completely understood, but it is generally accepted that they form from tractional pull on the calcaneus from the structures attached to the bone. This may include several muscles of the foot as well as the plantar aponeurosis.

Heel spurs are commonly associated with obesity, and can be seen in a number of different foot types. It has been reported that up to 92% of patients with heel spurs will develop ostephytes at other parts of their body. A heel spur on an x-ray can look like a very sinister problem, but it should be noted that the size of the heel spur does not correlate with the amount of pain associated with the problem. In fact, it is common to find that people will have heel spurs on both of their feet, yet only one side will be symptomatic.

Because both of the conditions are associated with each other, and the complaints of each are so similar, they may often be treated in the same manner. Generally a combination of rest, ice, stretching of the plantar fascia, and anti-inflammatory medications are sufficient in treating the conditions.

Strapping and taping are often employed by a physician to treat the problems, and orthotics may be prescribed as well. Functional orthotics may help to correct some of the biomechanical problems that lead to these two related conditions. By forcing the foot to function in a neutral position, much of the pull on the calcaneus can be eliminated. This can prevent the tensile pull on the calcaneus that can form heel spurs, as well as relieve the tension on the plantar fascia that may be causing the plantar fasciitis. Soft cushioning materials may also be used in the case of heel spurs to alleviate the pain.

Central Florida Foot & Ankle Center, LLC

101 6th Street N.W.

Winter Haven, FL 33881

Phone: 863-299-4551

www.FLFootandAnkle.com

Morton’s Neuroma

A neuroma is a benign growth in the tissue surrounding a nerve. This growth causes an enlargement of the nerve, which can lead to pain. Neuromas are fairly common in the feet, and are typically seen in the intermetatrsal nerves. These are the nerves that run up the metatarsal bones in your foot. The most common site for a nueroma to form is in the third intermetatarsal space, which is in the ball of the foot between the third and fourth toes. This is referred to as a Morton’s Neuroma.

Morton’s Neuroma can occur in anyone, but is most typically seen in females between the ages of forty and sixty. Early symptoms of a neuroma may include sharp or shooting pains in the affected area, a burning sensation in the area, or numbness and tingling in the toes. Many of these symptoms may resolve with rest and taking off the shoes, and you may feel some relief from rubbing the area. A common compliant of patients with a Morton’s Neuroma is that it feels like they are stepping on a pebble, or that there is a lump in their shoe.

There is no single clear cut reason that neuromas form, but there have been several proposed mechanisms. The one that is the most universally accepted is the idea that the neuroma is a response to the pressure of the metatarsals sqeezing on the nerve. This may be due to poorly fitting shoes, especially high heels. Why it occurs so frequently at the third intermetatarsal nerve in particular may be due to the thickness of this particular nerve – it is slightly thicker than the other intermetatarsal nerves.

The clinical picture of a neuroma is usually enough to diagnose the problem, but x-rays are usually taken to rule out things like stress fractures and other problems. MRI may also be used to diagnose neuromas more definitively, but due to cost is not generally done.

Treatment of neuromas including Morton’s Neuroma may include a change in shoes, padding, orthotics, medications, injections, and physical therapy. Generally a wider shoe will help relieve some of the pressure on the neuroma, which is often the source of the pain. Padding the area underneath the ball of the foot can also prevent the nerve from being pinched by the bones. Orthotics are typically used to treat biomechanical problems such as over-pronation, which may be the underlying cause of a neuroma. Injections of steroids as well as oral pain-relief medication are typically used in the acute setting, but will not address the underlying cause of the neuroma.

Ultimately, you and your doctor may decide that surgery is an option. This is generally a decision that will have to be made after some other therapies are employed first.

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

What is Clubfoot?

Clubfoot, or talipes equinovarus, is a fairly serious deformity of the foot and ankle that may be treated by a podiatrist or an orthopedic surgeon. It is defined as a deformity in which the ankle is in a fixed equinus position (meaning that the ankle is pointed down, or plantarflexed), and the rearfoot is in a fixed varus position (meaning that the heel is inverted, or pointed towards the middle of the body). These two abnormalities will additionally position the forefoot towards the middle of the body.

Clubfoot has an incidence of about 1-2 per 1000 live births. This number, however, increases with a family history of clubfoot. In those with a parent, sibling, or cousin with clubfoot, the incidence rate jumps to 1 in 20. When two family members were born with clubfoot, the chances are 1 in 5. Though the exact cause of talipes equinovarus remains unknown in the majority of cases, these numbers strongly suggest a hereditary nature of the deformity.

When a child is born with a clubfoot deformity, the situation is best addressed immediately, while the bones and ligaments of the foot and ankle are still the most pliable. This means that within the first 24 hours of the infant’s life, an attempt will be made to correct the deformity without surgery. Casting methods are used, where the foot, ankle, and leg are manipulated into a more normal position, and a cast is put on in an attempt to correct the positional deformity. Casts are changed every couple of days, until hopefully the deformity is corrected. The specifics of this casting technique were developed by Igancio V. Ponseti, MD, an orthopedic surgeon who just recently passed away at the age of 95.

In many cases of clubfoot, the Ponseti method is successful in correcting the deformity within the first six to eight weeks of life. Unfortunately, there are cases that do not respond to this casting technique, and surgery may be required to achieve a foot that is more functional. Additionally, some cases of clubfoot go unnoticed or undiagnosed until later in the child’s life, where non-surgical intervention may not be a viable option anymore.

Clubfoot is often seen co-existing with other musculoskeletal anomalies and other abnormalities. Some of these conditions include cleft lip, cleft palate, scoliosis, deformities of the upper extremities, torticollis (a fixed contraction of the sternocleidomastoid, a muscle in the neck), cardiac abnormalities, and hip dislocation. Clubfoot is also seen as an occasional or regularly occurring deformity in over fifty named congenital syndromes.

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