Patient Testimony after Dellon Procedure with Dr Wellens

Central Florida Foot & Ankle Center, LLC101 6th Street N.W.Winter Haven, FL 33881Phone: 863-299-4551http://www.FLFootandAnkle.com

Evaluating a Bunion

Evaluation of the condition we commonly call a 'bunion' is a rather complex process most podiatric physicians perform routinely. Many patients will present to the clinic with complaints of pain or pressure from "the bump on the inside of my foot." Of course, they will often call it a bump, bunion, or spur, but I have not yet had any patients present themselves complaining of their "hallux abducto-valgus deformity." Yet immediately, as a foot and ankle surgeon, I translate the "bump" into a triplane orthopedic deformity having osseous and soft tissue components and involving four separate bones. Interesting how quickly that happens when you think about it.

In the course of evaluation, clinical aspects such as how large the prominence is, how painful it is to pressure and movement, the tendency to track with range of motion, the extent and quality of motion, the amount of instability at adjacent joints, and secondary anomalies such as sub second metatarsal tyloma are noted. Plain-film radiographs are certainly a routine part of the complete examination, and will include the obligatory 3-projection series: dorsoplantar, medial oblique, and lateral images. From these projections, we define angulational values and make note of other anomalies such as degenerative joint changes, articular flattening, bone stock and width, and any adjacent conditions that may contribute to the deformity or require attention in the course of any corrective procedures.

Treatment options include bunion splint's, orthotics, anti-inflammatory medications, Cortizone injections, shoe gear modification,  and surgery as a last resort.

There are over 300,000 bunion operations performed in this country and overall it's a very successful way of helping with the deformity .

Surgery does require three weeks of wearing a boot but does not require any non weight bearing which used to be required in the past with older surgical procedures.

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

Plantar Fibroma

A plantar fibroma is a fibrous knot or nodule in the arch of the foot.  It develops as a benign growth of the fibrous tissue that makes up the plantar fascia, a large structure that runs along the entire plantar foot.  Plantar fibromas may develop in one or both feet, and will typically not resolve without treatment.  Fibromas develop as a defect in the growth of the fibrous cells, however, the exact mechanism that causes this is not clearly understood. 

Plantar fibromas begin as a noticeable lump in the arch of the foot.  They may increase in size over time, or may stay the same size.  They are firm to the touch, and may cause pain from an uncomfortable shoe irritating the lump.  However, not all people with plantar fibromas have pain as a symptom.  Generally plantar fibromas are isolated, but some people have several that develop on the same foot. 

A podiatrist may diagnose a plantar fibroma after examining the patient’s foot.  If there is pain associated with the lesion, it may recreate pain that extend into the toes.  MRI may be ordered in some cases to further evaluate the lesion with advanced imaging. 

Treatment of plantar fibroma begins with conservative therapy.  This may include anti-inflammatory medication if the lesion is irritating deeper structures, thereby causing pain.  A cortisone injection can also be used to help shrink down the fibroma.  This will typically only be a temporary fix, as the lesion may come back to original size. 

Accommodative orthotics may be used to relieve pressure to a plantar fibroma.  This is generally an orthotic with a piece cut out to fit the lesion. 

Surgical intervention relies on removing the lesion from the plantar fascia.  This should only be considered if the patient has not had any relief from conservative measures.  Typically, a small incision is made along the inside of the foot, and the fibroma is teased away from the plantar fascia.  Depending on the size and extent of the fibroma, some of the plantar fascia may need to be removed with the fibroma. 

Any new lumps or bumps on your feet, or on any part of your body for that matter, should be evaluated by a doctor promptly.  While most lesions are benign, some can be more ominous than others.  Plantar fibromas are just one example of a benign lesion that has a very small percentage chance of turning malignant.  For this reason, they should be evaluated thoroughly.  

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

Diabetic Charcot Foot

Charcot neuroarthropathy, often referred to as Charcot Foot, is an uncommon but devastating disorder of the bones and joints in the foot and ankle.  Most commonly Charcot Foot is seen in diabetic patients with neuropathy, but it has also been described in patients with neuropathy of other causes.

Charcot foot is characterized most frequently as a red, hot, swollen foot.  It is typically painless, as the patient is neuropathic.  Charcot foot is often misdiagnosed as gout, cellulits, or deep venous thrombosis (DVT).  This usually happens in a primary care or emergency setting, where the clinician may not have a high suspicion for Charcot foot.  The consequences of a missed diagnosis or delayed treatment include a bony deformity, which can lead to ulceration and subsequent infection.  Thus, early diagnosis and initiation of treatment by a trained foot and ankle specialist is essential. 

The “rocker-bottom” deformity is typical of Charcot foot that has affected the midfoot, as is the case with the majority of patients.  This refers to an increased convexity of the bottom of the foot that is the result of excessive midfoot collapse.  When this happens, bone can protrude, which causes increased areas of pressure on the skin.  This increased pressure leads to ulceration if not addressed.

The pathophysiology of Charcot foot has been debated in the past, however current practitioners generally agree on the cause as a combination of neurovascular dysregulation and trauma to the foot or ankle as the inciting event.  The neurovascular dysregulation causes increased blood flow to the feet, which can “wash out” some of the bone density, making the bones and joints of the foot susceptible to injury.  Trauma may be in the form of a singular acute event, such as a fracture, but may also be from repetitive microtrauma from a previously existing foot deformity or a poorly fitting pair of shoes or a sudden increase in activity.  The uncontrolled inflammation associated with Charcot foot causes an increase in osteoclast activity, the cells responsible for degrading bone. 

Diagnosis of Charcot foot is made mostly as a clinical diagnosis.  The foot will appear red, hot, and swollen, and there may be a significant temperature difference between the feet.  X-rays are taken, but may only show subtle changes in bone quality and joint alignment if it is very early in the disease.  MRI can also be used to examine the bones and joints of the foot or ankle, but is not necessarily diagnostic of Charcot foot.  This is because the Charcot foot may look very similar to osteomyelitis, or an infection of the bone.  However, the information provided by imaging studies such as x-rays and MRI can help the clinician in diagnosing Charcot foot.

The most important aspect of treatment for Charcot foot is offloading of the affected foot.  This means that there is no weight placed on the foot.  This can be done by casting with either plaster or with a removable cast.  Some patients may be able to use crutches or a walker while the cast is on, however, for many patients a wheelchair is recommended.  This is due to the fact that excessive pressure on the unaffected site may lead to increased trauma to that side, thus possibly initiating a Charcot foot on the other side.  Approximately 30% of patients affected by Charcot foot will go on to develop Charcot foot on the opposite side. 

Medical treatment with bisphosphonates, drugs traditionally used to treat osteoporosis and some other disease of bone, has shown to be of some benefit to patients in some small study groups.  These drugs may include pamidronate (Aredia) or alendronate (Fosamax).  Treatment with intranasal calcitonin spray has also been used.  Calcitonin is a naturally occurring hormone that helps to regulate calcium and bone density in the body.  Additionally, some doctors have used anti-inflammatory medications in an effort to restrict some of the uncontrolled inflammation associated with Charcot foot. 

Surgical treatment can also be used to help patients with Charcot foot.  For patients with advanced deformities related to Charcot foot, surgery can be used to establish a more normal appearing foot, which can then be placed in a customized shoe or Charcot restraint orthotic walker (CROW).  The goals of surgery on the Charcot foot are to heal any current ulcers, prevent future ulceration and infection, and to fit the patient to a customized device.  These devices are generally worn by a patient with Charcot foot at all times, and are considered to be lifelong devices. 

Charcot foot continues to be an area of interest and research for many podiatric surgeons, and is an extremely debilitating and devastating syndrome.  The patients who develop Charcot foot need a lot of attention and counseling regarding their foot deformity, and adherence to medical and surgical treatment plans is essential for healing and for positive outcomes.  Charcot foot remains a difficult problem to treat, however, advances in the understanding of the syndrome and advances in technology have made for better outcomes. 

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

Dwayne Wade Still Sitting Out With Sprained Ankle

Last Friday, Miami Heat star Dwayne Wade added yet another injury to his list.  After landing awkwardly on his ankle while going after a loose ball, Wade left the game and didn’t come back.  Last night he sat out again as the Heat took on the Spurs.  The Heat were able to defeat the Spurs easily without Dwayne Wade, who remains out with a sprained ankle indefinitely. 

Ankle sprains are a common injury, particularly in athletes.  Most commonly an ankle sprain occurs from an inversion injury, where the ankle is forced to roll outward over a stationary foot.  Less frequently, a medial sprain may occur where the ankle rolls medially (towards the middle of the body). 

Inversion injuries such as Dwayne Wade suffered from on Friday can result in a number of different injury patterns, and can frequently involve a fracture of one or more bones of the ankle or foot.  Thankfully, the x-rays were negative for fracture in this case. 

The lateral ligaments of the ankle include the anterior talofibular ligament, the calcaneofibular ligament, and the posterior talofibular ligament.  In a lateral ankle sprain, one or more of these ligaments may be injured.  Generally speaking, the anterior talofibular ligament is injured first, followed by the calcaneofibular ligament.  The posterior talofibular ligament is less frequently included in these types of injuries. 

The degree of the sprain is often defined as well.  The degree of the sprain refers to the amount of damage to the injured ligament.  If the ligament is not torn at all, it is considered a first degree sprain.  In second degree sprains, a partial tear may be seen.  In third degree sprains, the ligament is entirely ruptured and may even require surgical repair in some cases.  The degree of the sprain is often evaluated with an MRI. 

In Dwayne Wade’s case, he is walking without a cast or surgical boot.  This is a good sign, as it indicates that the sprain is less severe.  Still, this injury comes as Dwayne Wade was already nursing a sore left foot and a muscle strain in the calf.  Rehabilitation of these injuries is certainly a concern for the Miami Heat, who are searching for a championship in this abbreviated season.  While they seem to be able to still win with Dwayne Wade on the sidelines, it begs the question if they can continue to win in the post-season without the star guard.  

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

Meralgia Paresthetica

Meralgia paresthetica is an uncommon pathology of the lateral femoral cutaneous nerve.  It is most commonly caused by entrapment of the nerve as it courses through the inguinal ligament.  The nerve originates from the spinal cord at the L2-L3 level, and courses underneath the inguinal ligament as it travels into the thigh.  The nerve has no motor control, but it relays sensory information from the anterior-lateral thigh. 

Symptoms of meralgia paresthetica include a burning, tingling, numb, or painful sensation to the anterior-lateral thigh.  Most commonly it affects only one side of the body, but may affect both sides at the same time.  There is no loss of strength associated with meralgia paresthetica, as there is no motor function of the lateral femoral cutaneous nerve. 

The condition is most commonly caused by compression of the nerve, particularly underneath the inguinal ligament.  This compression may come from a heavy tool belt or utility belt applying pressure to the nerve, or it can come from increased pressure from the abdomen in obese individuals.  Rarely, the symptoms come from a space-occupying lesion along the nerve contents such as a tumor, or from a lesion along the psoas muscle. 

The diagnosis of meralgia paresthetica is made through clinical exam.  Tapping along the inguinal ligament may reproduce the symptoms, which is highly suggestive of meralgia paresthetica.  Occasionally EMG or nerve conduction studies may be ordered, however, this is usually only the case when ruling out pathology of the spinal cord, nerve roots, or compression of other nerves of the lower extremity.  In particular, pathology of the femoral nerve may present with similar symptoms, but will also show a loss of strength in the quadriceps muscle.

Treatment of meralgia paresthetica is supportive.  Weight loss in obese individuals has been shown to relieve symptoms.  Removal of a heavy tool belt or other form of compression along the nerve will also generally relieve symptoms.  Medications used for nerve pain such as gabapentin may also be used, with some patients reporting good results.  Injections with local anesthetics and steroids may eliminated pain temporarily, for a long period of time, or even permanently.  Surgical decompression of the nerve may be performed, but is reserved for unrelenting conditions.  Interestingly, meralgia paresthetica has been shown to be more common in diabetic individuals than in the general population, after controlling for weight differences.

If you have symptoms of meralgia paresthetica, or of any other nerve compression, it is important to discuss this with your doctor. Be sure to tell them of any other symptoms that may be associated with the pain, such as muscle weakness or fatigue, changes in vision or hearing, or numbness and tingling in any other parts of the body.

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

The Subtalar Joint

The subtalar joint sits below the ankle joint, and is composed of the articulation between the talus and the calcaneus.  It plays a crucial role in the normal function of the foot, and allows for motion along an axis that runs through three planes of the body; the frontal plane, the sagittal plane, and the transverse plane.  Motion along the subtalar joint axis is defined as pronation and supination.  The pronation and supination allows the foot to adapt to uneven surfaces, and functions as the connecting joint between the ankle and the rest of the foot. 

The articulation between the talus and the calcaneus is actually composed of three separate articular surfaces; the posterior articular facet, the middle articular facet, and the anterior articular facet.  Together, these three articulations create a joint between the two bones. 

The joint is stabilized by a number of ligaments that connect the talus to the calcaneus.  The ankle ligaments also help to stabilize the talus within the ankle joint, and keep it improper alignment with the calcaneus.

Pathology of the subtalar joint may include primary osteoarthritis, arthritis secondary to fractures of the ankle and/or calcaneus, tarsal coalition, inflammatory conditions, and a number of other problems that can affect bones and joints.  Subtalar joint arthritis is a very common etiology of subtalr joint pain.  When the subtalar joint becomes an area of pain, it is often confused for ankle pain.  Thus, when people come to the doctor with a complaint of ankle pain, they are often shocked to find out that it is not actually their ankle that hurts, but their subtalar joint. 

Subtalar joint pain, particularly when it is due to arthritis, can be differentiated from ankle pain with a careful clinical exam, as well as the use of diagnostic injections.  Diagnostic injections involve injecting a small amount of local anesthetic, a numbing agent, into the painful joint.  If all of the pain is relieved, than it can be deduced that the subtalar joint is the source of pain.  If some, but not all of the pain is relieved, than it is possible that the ankle or other surrounding joints, or the soft tissues around the joint may be the source of the problem. 

Treating subtalar joint arthritis begins with conservative therapy.  This may consist of various padding and strapping methods, orthotics, and the use of cortisone injections into the joint.  Oral anti-inflammatories, ice, physical therapy, and other modalities may be tried as well.

Occassionally, the arthritis is severe enough to warrant surgical intervention.  Most commonly, subtalar joint arthritis is treated surgically with a fusion of the joint, also known as an arthrodesis.  In subtalar joint arthrodesis, the talus is fused to the calcaneus.  This removes all motion available at the joint, thus eliminating the pain associated with its movement.  The joint will not move after it has been fused. 

Screws are used to hold the bones in place while they heal together, and a period of non-weight bearing is generally employed for a minimum of 6-8 weeks.  After this period of time, the patient may be transitioned to a partial weight-bearing status, for another period of 4-6 weeks.  After the bones have completely healed, normal activity may begin again.

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

Plyometrics for Lower Extremity Power Training

Plyometrics is a form of exercise that is designed to improve muscular power, speed of contraction, and improve the response time of the neuromuscular system. It is typically used by competitive athletes as a form of cross-training, but recently has become more po pular in the non-professional athletic community. The technique involves combining muscle loading and fast contractions in order to improve muscle power. Muscle power includes not just strength of muscles (i.e., how much weight a person can lift) but also considers the speed at which that force is delivered.

In particular, plyometrics are used to strengthen and train the muscles and reflexes of the lower extremity, as well as improve core strength. Research has shown that the use of plyometrics in professional athletes has increased performance as well as decreased the incidence of injury.

Specific exercises include a variety of different lunge and squat techniques. The plyometric exercise consists of a fast elongation phase of contraction (eccentric phase) followed by an amortization or resting phase, which is then followed by a short burst contraction phase. For example, this may involve a quick squat, followed by a brief period of rest, followed by a jump off the ground.

The science behind plyometrics revolves around the specific muscle fibers being trained. The muscle fibers of the body consist of slow-twitch (type I), fast twitch type A (type IIA), and fast twitch type B (type IIB). In plyometrics, the fibers being worked are the fast-twitch fibers. Plyometrics also helps train the muscle reflexes that help control muscle contractions.

Plyometrics can be a excellent adjunct to an training or exercise program, but should only be undertaken by those in good physical condition. Because of the high impact nature of many of the exercises, those engaging in plyometrics should be ready for this impact. The technique used is of utmost importance, so as to avoid injury when training. Age is also a consideration, as many people of advanced age are advised against high impact activity due to arthiritis, osteoporosis, or other conditions that may jeopardize the safety of the individual.

There is not usually much equipment required for plyometrics. Generally a pair of sturdy training shoes designed for lateral movements, comfortable clothes, and enough space to move around is all that is needed. Many people follow instructional videos, or participate in organized classes that can help with technique. Plyometrics is an intense workout, so if you’re planning on trying it, be sure that it is safe by talking to your doctor about your new exercise plan. And bring plenty of water.

Central Florida Foot & Ankle Center, LLC

101 6th Street N.W.

Winter Haven, FL 33881

863-299-4551

www.FLFootandAnkle.com

Smart Toe implants for Hammertoes

Hammertoes involve a contracture deformity at one or more of the joints in the toe. The most common deformity seen involves a flexion contracture at the proximal interphalangeal joint and an extension contracture at the distal interphalangeal joint. There are also isolated deformities of the distal interphalangeal joint known as mallet toe, and dual flexion contractures at the distal and proximal interphalangeal joints known as claw toes. A deformity may also be present at the metatarsophalangeal joint in any of these hammer digit variations.

Clinically, it is important for the evaluating physician to recognize if the deformity is flexible or rigid. Flexible deformities can be treated in some cases conservatively with orthotics, which serve to neutralize the deforming forces. Hammertoes are typically caused by a biomechanical abnormality that leads to a loss of muscle balance in the digits. Flexible hammertoes can also be treated surgically with a flexor tendon transfer or a simple flexor tenotomy.

For rigid deformities, conservative therapy involves accommodation and palliation. Corns that develop from the prominent joint rubbing against shoes can be shaved down, and corn pads and toe spacers can be used to make the person more comfortable. Wider and deeper shoes will also help for many.

Surgical correction of a rigid hammertoe can involve either an arthroplasty or an arthrodesis. Arthroplasty involves cutting some of the bone out of the joint, which creates a wider, more mobile joint. Arthrodesis is a fusion of the joint, which helps to straighten out the toe. The Smart Toe implant is a newer piece of hardware that helps in arthrodesis procedures.

The smart Toe device is placed in the two bones that create the joint, either at the proximal or distal interphalagenal joints of the digit. This allows for a fusion of the joint. The hardware is composed of metal that expands once placed into the body, and keeps a rigid fusion of the joint. They are kept frozen, and heat allows them to expand. Using a Smart Toe avoids having a pin coming out of the tip of the toe, which can potentially lead to infection or loss of correction at the joint.

Smart Toe comes in both straight models and in models that have a slight bend to them. The 10 degree bend allows for the tip of the toe to touch the ground easier, and provides a more natural looking correction. Smart Toe has become a popular option in the treatment of hammertoes by podiatrists, due to the ease of use and to patient satisfaction.

If you are considering treatment for hammertoes, talk to your provider about the different options, and which options would be best for you.

Central Florida Foot & Ankle Center, LLC

101 6th Street N.W.

Winter Haven, FL 33881

Phone: 863-299-4551

www.FLFootandAnkle.com

Corns and Calluses

Corns and calluses of the feet are a common problem for many people. They develop because of repeated friction to the area. This may be the result of poorly fitting shoes, or biomechanical abnormalities that cause a person to put excessive pressure in one area of the foot. A corn develops on either the top or outside of the foot, while a callus develops on the bottom of the foot. Corns are usually in one particular area, such as on the tops of the toes, while calluses can be more diffusely located on the bottoms of the feet. A corn can also develop in between the toes as a result of the bones of the toes rubbing against each other and the skin between them becoming thickened. When this occurs, the corn is known as heloma molle.

A corn will appear as a thickened lesion, which may or may not be painful. Because of the increased friction to the area, the body's response is to increase skin production to protect the tissues below the skin. This is what causes the skin to thicken, become dry and flaky, and to often become elevated compared to the surrounding skin. Corns and calluses may become painful if they are neglected.

Generally, corns and calluses are not a huge problem. They can cause local discomfort, but will usually resolve quickly when the outside force causing increased pressure or friction is removed. This may be something as simple as changing a pair of ill-fitting shoes or using a small piece of padding in the area.

For diabetics and other people prone to peripheral neuropathy, corns and calluses can be more of a concern. Becuase of the loss of sensation to the feet in diabetic and other forms of peripheral neuropathy, a person may never feel the pain from increased friction and callus formation. Without feeling that pain, the skin can break down and an ulcer can form. When an ulcer forms, they can be very difficult to treat and rely on off-loading the area to remove unwanted pressure. Because of this concern, it is important for diabetics to check their feet daily, and to have their doctor or podiatrist inspect them as well.

Professional treatment may become necessary when corns and calluses become painful, particularly if it is difficult for one to care for their own feet. This would include elderly and diabetic populations, as well as those with chronic back pain and other conditions limiting mobility. Removing the callus with a scalpel blade is often a quick way to make a patient feel better. Treatment should also focus on removing the causative factor of corns and/or calluses. This may include padding, strapping, or orthotics. In some situations when a bony prominence may exist causing undue pressure and pain in the area, a small piece of the bone can be removed surgically to relieve the pressure.

Central Florida Foot & Ankle Center, LLC

101 6th Street N.W.

Winter Haven, FL 33881

863-299-4551

www.FLFootandAnkle.com