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12/24/2011
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: Orthotic Therapy For Hallux Rigidus (John Scholl, DPM)
From: Ron Bar, PhD, Elliot Udell, DPM
A cut-out of the orthotic under the hallux reduces the need for dorsi-flexion at the 1st MP joint, alleviating pain in cases of hallux rigidus or limitus. This should be accompanied with shoes that offer a substantial toe-spring, which also enable the foot to move forward without the need for extensive dorsi-flexion. The problem is – it is impossible to determine if a shoe features a toe-spring, or it is made with a dorsi-flexed last, as from the outside, we can only see the clearance under the toes, but cannot tell how the shoe is constructed. Shoes with a true toe-spring are made with a sole which is thick at the midfoot, and gradually becomes thinner towards the tip of the toes.
In the case of shoes that are built on a dorsiflexed last, and normally don’t feature soles that become thinner towards the tip of the sole, the digits are pushed up, causing excessive dorsi-flexion at the 1st MP joint, and pain for people with hallux rigidus. Most running shoes come with soles that feature a true toe-spring design. All Orthofeet shoes, including men’s and women’s dress shoes feature Ergonomic Stride TM design with a true toe spring.
Ron Bar, PhD, Orthofeet, Inc. orthofeet@aol.com
My clinical impression, based on the AP radiograph submitted, is that there appears to be enough cartilage present to allow for a greater degree of dorsiflexion. There is joint narrowing, but I see worse in my office every day. It is likely that the cause of the problem is locking due to the spurs present which are visible on the lateral view. These may have to be surgically removed. If you want to try conservative measures first, take a role of adhesive-backed 1/8th inch felt, which is available from any podiatry supplier, and make a Morton's extension and tape it on to the affected foot. Have the patient try it for a few days to see if it works. Have the extension go to the tip of the hallux.
If this helps, then order an orthotic and make sure the lab incorporates exactly what worked with the felt into the actual orthotic. Having the patient do exercises where the toe is pulled forward dorsiflexed to max and then plantarflexed to the max, may also help. My gut feeling, however, is that nothing will help until those eburnations are surgically removed.
Elliot Udell, DPM, Hicksville, NY, Elliotu@aol.com
Other messages in this thread:
05/14/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: Non-Union and Malunion of Metatarsals (Bret Ribotsky, DPM)
From: David Secord, DPM
Maybe it's just me, but I'm confused by this post and the responses. With all due respect to Dr. Ribotsky and his comment “but that's why we love what we do, helping people with real problems,” isn’t the real problem here the patient and her malignant non-compliance issues? The prior procedure looked as though it was done competently with a pretty good hardware count and investment of time. If the patient had been compliant with post-operative orders, it would, most likely, have turned out fine.
I’m of the opinion that if you’re not willing to help yourself (i.e., be compliant with post-operative orders concerning weight-bearing status, nutrition, cessation of nicotine, and that sort of thing) and destroy a perfectly good surgery, why waste more time? This patient didn’t even seem to be ashamed of walking around in a regular shoe until it started hurting. I think that just reading a few of the posts in the Jury Verdict Reporter in PM News would make anyone walk away from this disaster.
David Secord, DPM, San Juan, TX, secord@medscape.com
05/08/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
From: Barry Mullen, DPM
In CRPS, vasomotor changes usually do not manifest until its latter stages. That's a point a clinician wants to try to avoid. I'm confident that one month post-crush injury is simply not long enough to establish those signs, so their absence still does not rule out CRPS. The lack of follow-up from the referred specialist makes no sense and is disturbing.
I'd certainly want an explanation why they did not re-evaluate the patient's lack of response. Round one of PT didn't help - what therapy was tried? CRPS resolution often proves challenging, so before one throws in the towel in favor of malingering, a different therapeutic approach is likely warranted.
05/03/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: Recent Research Confirms Therapeutic Effect of Foot Orthoses for Anterior Knee Pain) Kevin Kirby, DPM)
From: Jeff Root
Kevin Kirby, DPM is one of the most knowledgeable people in the world when it comes to research related to foot orthotic therapy. It comes as no surprise to me that he was kind enough to take the time to post a letter in the 4-30-12 issue of PM News in order to highlight a study examining the efficacy of foot orthoses in the treatment of patellofemoral pain syndrome in an effort to help educate his colleagues. The objective of this study outlined by Dr. Kirby was simply to investigate the short-term clinical efficacy of three pre-fabricated orthoses as compared to a “wait-and-see” approach to treatment.
In the very next issue of PM News, there were two letters questioning the methodology of the study. Obviously the study was not designed to compare...
Editor's Note: Mr. Root's extended-length letter can be read here.
05/02/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
From: Barry Mullen, DPM
Malingering is always a possibility with Workers' Comp cases. However, I tend to err on giving patients the benefit of the doubt. That said, exactly what do we know about this case?
a) documented foot crush injury (I'm curious how heavy the buggy is and when injury occurred relative to your exam?);
b) subjective pain complaint is described with neuritic descriptors, AND out of proportion to physical signs;
c) patient refuses to move digital extensors = classic...
Editor's note: Dr. Mullen's extended-length letter can be read here.
04/16/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: Excisional Biopsy (Gino Scartozzi, DPM)
From: Simon Young, DPM, Hilaree Milliron, DPM
Dr. Scartozzi brings up a valid point. This could be done with an ultrasound. Check compressability. Use a duplex Doppler component to check for vascularity.
Simon Young, DPM, NY, NY, simonyoung@junocom
I suggest pre-operative imaging to delineate margins, depth of involvement, anatomic detail, and mass characteristics, etc. An MRI, with and without contrast, should be sufficient. Many assumptions can be made as to benign/malignant characteristics simply from imaging. Those characteristics and anatomic detail will be altered post-operatively. Please image and have it read by a reputable radiologist before you even consider biopsying suspicious lesions.
Hilaree Milliron, DPM, Jacksonville Beach, FL, millirondpm@gmail.com
04/12/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: Metatarsus Adductus in a 14 Month Old (Edmond F. Mertzenich, DPM)
From: Gino Scartozzi, DPM
Although the child has started walking, I recommend that the metatarsus adductus can and should be treated. One would have to rule out a concomitant equinus and varus deformity of the foot which may be overlooked as a mild clubfoot deformity.
The use of a Beebax bootie which the child can wear at night and when napping can be helpful, even if surgical intervention will be required. The forefoot region of the boot can be adjusted slowly over time by abducting the forefoot onto the rearfoot component of the shoe. The rearfoot (subtalar joint) component of the shoe can be adjusted to a position of inversion relative to the forefoot component of the shoe to prevent talo-navicular subluxation. The further use of orthoses is helpful to maintain the correction obtained.
Gino Scartozzi, DPM, New Hyde Park, NY, Gsdpm@aol.com
04/11/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: S/P Fracture Left Ankle (Philip Graham, DPM)
From: Ron Werter, DPM
Of course she would have pain with weight-bearing after less than 2 weeks. Dr. Graham didn't mention her body size and conditioning. If she can be compliant with using crutches for non-weight-bearing for the next 3-4 weeks, even with the 4 nicotines per day, it should do well without surgery. It all depends on how well you trust her, which is also the case if you do surgery. Also, have her stop smoking. A bone stimulator also helps, if you can get one for her.
Ron Werter, DPM, NY, NY, Hawkeyedpm@aol.com
04/10/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: Diabetic Ulcers With Verrucae (Jordon Sheff, DPM)
From: Gino Scartozzi, DPM
The fact that the patient apparently has an ulceration with a concomitant "verruca" present would lead one to suspect certain issues with this patient. These issues can impact on your treatment and prognosis for resolution. I would be suspect of the pathological diagnosis of "verruca" that is concomitant with this ulceration. Biopsy at SEVERAL sites of the ulceration should be retaken to determine the etiology of this "ulceration" if it has not been done already. I have treated long-standing ulcerations of other physicians that have turned out to be carcinomas of squamous cell and basal cell varieties.
If the diagnosis is "verruca," your patient is in an immunosuppressed health state. One would have to be suspect of the patient's diabetic control and any other co-existing medical issues that can impede the patient's ability to heal the ulceration and develop a cell-mediated response to resolve his/her "verruca." The ulceration with a diabetic in such a state, even with "good pulses," places a higher priority in their treatment over any verruca treatment regimen, since an ulceration with concomitant infection places higher morbidity/mortality risks on your patient.
Treatment that should be considered would include vascular assessment; bacterial cultures post-debridement; determination of the patient's hemoglobin A1c levels, albumin and pre-albumin levels; radiographs to exclude osseous pathology/infection; diminishment of weight-bearing stresses on the ulceration site during and after wound care healing, and appropriate wound care for this patient. Surgical intervention of the ulcer may be considered if the ulceration recurs with proper pre-surgical evaluation/planning.
Gino Scartozzi, DPM, New Hyde Park, NY, Gsdpm@aol.com
03/24/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
MI Podiatrist Leads "Walk With a Doc" Event
The March Walk with a Doc program at Heritage Park last week took place under sunny skies and brought out some 35 people, one of the largest turnouts so far. The free program is open to the community and is for all ages and fitness levels.
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Dr. Susan King |
Healthcare professionals are available for discussions, blood pressure monitoring and more. This time, Dr. Susan King, podiatrist, talked about selecting the right walking shoes, and injury prevention and care.
Source: Susan Steinmueller, Observer and Eccentric [3/22/12]
03/17/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: Lapidus or Fusion (Philip Graham, DPM)
From: Richard Gosnay, DPM
As Dr. Solomon has deftly demonstrated, the first MTPJ fusion can powerfully affect the transverse plane orientation of the first ray. In my experience with the Lapidus procedure, positioning the first metatarsal head over the sesamoid apparatus restores much of the MTPJ alignment but may require a further head procedure, as noted by Dr. Mullen. Dr. Mullen's advice about addressing the goals and expectations of the patient, despite her chronological age, is also wise.
Regarding this particular case, my judgment is driven by the degeneration of the lesser digits and MTPJs secondary to the first ray insufficiency. The Lapidus fusion will restore the sagittal plane orientation of the medial column in addition to correcting the transverse plane deviation of the first metatarsal. A further modified Reverdin procedure may also be required. Of course, the lesser toes would require arthrodeses in order to restore their orientation. The extent of second toe deformity in the sagittal plane suggests plantar plate disruption which is typical of the lesser ray damage seen with long-standing, first-ray incompetence. I would expect that a Girdlestone tendon transfer would also be needed to restore the second toe sagittal plane alignment.
Richard Gosnay, DPM, Danbury, CT glabroushead@gmail.com
03/14/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: Lapidus or Fusion (Philip Graham, DPM)
From: Will Godfrey, MA, DPM
I recommend doing both procedures using AccuMed Plates & Screws (titanium). Early ambulation is permitted in a walking boot as the fixation construct is so very incredibly stable. Of course, it's dealer's choice: one may want to separate procedures to (1) reduce the operative and tourniquet time (which is good in older, more fragile patients), and (2) to avoid the 50% reduction of fee payment for the second procedure.
The AccuMed reamers make the procedure for 1st MTPJ fusion go quickly. Remove the hardened plate of bone immediately below the damaged/arthritic cartilage (sub-chondral) and fenestrate with a small drill tap, which makes for a fast healing time. I typically see bony bridging on x-ray as early as 4-5 weeks (that is, in the young, healthy, non-tobacco users).
Use the same set (AccuMed Foot/"Small bone-joint Fixation set") for the Lapidus. Note that AccuMed's plates come in left and right, and in sizes; as well as with pre-sizing templates, so one does not have to 'touch' the foot intra-operatively with any implant they are not going to end up using.
Will Godfrey, MA, DPM, Horizon City, TX, williamtrekkie@earthlink.net
03/13/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: Lapidus or Fusion (Philip Graham, DPM)
From: Jeffrey Kass, DPM
I think that this case is interesting and challenging and thank Dr. Graham for bringing it to the forum. I also thought the remarks about knowing one's limitations were uncalled for.
I also disagree that a 1st MPJ fusion can't correct for high IM angles. Two years ago, at the NY clinical conference, Tzvi Bar David, DPM gave multiple case presentations on this exact issue.
I think Dr. Graziano gave sage advice about treating the patient and not the x-ray. Dr. Scartozzi brought up some key points, that for completeness sake, I'd like to expound on. The range of motion in this case is pretty normal with mild pain on end range of motion. The joint is subluxed, and hence if the joint was made congruent, ...
Editor's note: Dr. Kass's extended-length letter can be read here.
03/12/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: Lapidus or Fusion (Philip Graham, DPM)
From: Marc Garfield, DPM
Dr. Graham did not mention the patient’s weight, activity demands, general health, or limitations. Some 67 year olds are very spry and active while others have had two bad knee replacements and sit and knit. 67 is a very transitional age. Bone mineralization is decreasing and the needs and abilities or self-sufficiency need to be carefully reviewed before casting this woman for 10 weeks.
Is she willing to undergo DVT prophylaxis during that time? Can she be non-weight-bearing for the recovery? Would a Keller help her enough to be worthwhile even if she still has a bunion when you are done? Most people in this age group are scarcely prepared for the type of recovery that you will subject her to. But, if this is painful for her and she is very active and willing to do what it takes to get the most anatomical and stabilizing correction possible, then the Lapidus would likely offer...
Editor's Note: Dr. Garfield's extended-length letter can be read here.
03/06/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: Painful, Discolored Toe (Chuck Ross, DPM)
From: Gino Scartozzi, DPM,Stephen Musser, DPM
I always have a saying in medicine, "when in the forest, you are more likely to see a deer than a zebra." However, the occasional "zebra" will present itself rarely with the patient seeking care. In this case, did the patient have a cardiac or other vascular thrombolic event that dislodged and now manifests itself into the toe? Probably not, since the patient is described as "healthy."
In regard to the second toe of the right foot being in a significantly more elongated state, repetitive micro-trauma, either due to the patient's activity level and/or shoe wear, is probably the culprit. The atypical presentation of a unilateral involvement of Raynaud's syndrome or disease I cannot ever recall seeing in my practice. However, micro-vascular injury from such trauma with its associated symptoms should be addressed. Suggestions of shoe/activity modification, oral non-steroidal anti-inflammatory medications, and vascular assessment may be indicated if the provider feels that such arterial supply has been significantly compromised.
Gino Scartozzi, DPM, New Hyde Park, NY, Gsdpm@aol.com
Raynaud's phenomena would be lower on my differential diagnosis list (is there any involvement with the fingers?). With the information provided, I would include the following in my differential: 1) 'sausage digit' (treat appropriately). (2) did the patient have a recent medical test/procedure where she may have thrown a clot that lodged in her toe? 3) an atypical presentation of gout (is she taking a diuretic, low dose ASA?). Any labs ordered?
Did you measure her feet to determine if her footgear is appropriate? This would help rule out the Morton's foot type being a contributing factor. This is an interesting case. Write back and let us know how it worked out.
Stephen Musser, DPM, Cleveland, OH, ly2drmusser@gmail.com
03/02/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: Plating Choices (Mario Dickens, DPM)
From: Greg Caringi, DPM, Tip Sullivan, DPM
Before considering which plating system to use, consider the use of a bone growth stimulator. The fracture is reasonably well-aligned and opposed, and the bone callus is a good prognostic sign for healing. I've had very good results with the Exogen Ultrasound Bone Healing System from Smith & Nephew.
Greg Caringi, DPM, Lansdale, PA, drgregc@msn.com
Unfortunately, no clinical history was provided, which is extremely important in making these types of decisions. It's not simply whether or not surgery is needed vs. immobilization, nutritional consult, PEMF stimulation, etc. but also the patient's weight, activity, job, health, and foot function should all be used. This is an example of the art we work in — trying to combine the best treatment in the appropriate case.
If this were a healthy compliant person and I could use whatever I wanted from an insurance (cost) standpoint, I would use an autologous graft (easily obtained with a bone dowell) and a small (Wright Medical) locking plate (at least 5 holes). In my hands, this is the most stable construct for an ORIF. You certainly could put an Ex-fix on this, but I have found that the pin care and risk of complications (I have seen stress fractures across the pin holes) just make it easier to use ORIF.
Tip Sullivan, DPM, Jackson, MS, tsdefeet@MSfootcenter.net
03/01/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: Large Verruca at the Heel (Bruce Krell, DPM)
From: Pete Harvey, DPM, Jeffrey Kass, DPM,
I had a very similar verruca presentation about four years ago. She had been seen and treated by multiple other doctors for verruca that looked exactly like the one shown. I did a 2 mm biopsy on her first visit which came back as melanoma. I referred her to oncology and plastic surgery. She followed up with her M.D. She is still under care, and is doing well.
Pete Harvey, DPM, Wichita Falls, TX, pmh@wffeet.com
1. Biopsy the lesion. 2. There is likely a problem with the patient's immune system, if indeed, the lesion is a wart. This should be looked into. I have read anecdotal reports regarding resistant veruccae and Vitamin D deficiency/insufficiency so this may be a place to start. 3. For larger size warts, I like a pulse-dye laser as a treatment, and I have found success with multiple treatments.
Jeffrey Kass, DPM, Forest Hills, NY jeffckass@aol.com
02/29/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: Large Verruca at the Heel (Bruce Krell, DPM)
From: Andrew Levy, DPM, Stephen Musser, DPM
My first recommendation would be to get a good current biopsy. Malignant transformation to verrucous carcinoma, while rare, is a definite possibility that needs to be ruled out before other treatments are entertained.
Andrew Levy, DPM, Jupiter, FL, rcpilot48@gmail.com
As we are all aware, there is no 'sure fire method' of getting rid of plantar warts. Because this patient has an immune issue, I would make her aware that there are no guarantees that any treatment modality will work. Second, if she has a hyperhidrosis problem, you need to address that issue.
If the verruca is minimally painful, I would use a duel combination of Efudex Cream at night and cover with a bandage followed by using Plantar Stat(or something similar) every morning. If the lesion is moderately or severely painful, I would opt to curettage the lesion and if the lesion recurs, I would start the Efudex/ Plantar Stat combination.
Stephen Musser, DPM, Cleveland, OH, ly2drmusser@gmail.com
02/22/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: Unknown Lesions on Legs (Razi Ahmed, DPM)
From: Robert J Snyder, DPM
The lesions could be an atypical pyoderma gangrenosum; biopsies are usually negative or reveal neutrophilic infiltrates. The diagnosis therefore is one of exclusion and there is no underlying disease in 50% of cases. Also consider pemphigoid and perform immunoflorescence the next time the lesions erupt.
Robert J Snyder, DPM, Tamarac, FL, drwound@aol.com
02/18/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: Gouty Tophi, 3rd Digit (Charles Baik, DPM)
From: Stephen Musser, DPM, Chris Browning, DPM
As long as the patient is a good surgical risk (diabetes control, pedal pulses intact, compliance, etc.), amputation of the digit is a practical solution to this problem. Be sure to have the patient follow up with the primary physician for control of the gout. Make the patient aware of the surgical cons and that the possibility for further surgical intervention in the future may be necessary.
Stephen Musser, DPM, North Olmsted OH, ly2drmusser@gmail.com
Amputation is a very excellent option for a patient with tophaceous gout, especially when the case is as far advanced as your patient's case appears in the photo. I have seen these same patients have a chronic draining wound from which one can constantly express tophaceous material. Often times, on x-ray, the bones are dissolved, leaving just a bag of tophus. This chronic wound, often coupled with microvascular disease, can also be seen with cellulitis of the toe and even osteomyelitis. You are right on track with your choice to amputate!
Chris Browning, DPM, Temple TX, chrisbrowning@att.net
02/10/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: The Use of Uloric vs. Allopurinol in the Management of Gout (Peter Vannucchi, DPM)
From: Frank Lattarulo, DPM
The thought of treating gout with colchicine and local anesthetic and/or steroid has always been a staple of our practice, but the question becomes what do we do about colchicine which, in most markets, is now unavailable leaving us few options. Given that allopurinol is not effective in acute flares, why not simply go with local steroid intra-articularly and oral NSAIDs, then back to the PCP? Seems we are spending a great amount of effort on this seemingly basic treatment.
Frank Lattarulo, DPM, NY, NY, doclatt@aol.com
02/08/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: Treatment Options Talocalcaneal Coalition (Edmond F. Mertzenich, DPM, MBA)
From: Robert D. Phillips, DPM
Mert Root taught me a good approach to these types of coalitions, which has served me well for a great majority of the tarsal coalitions. Unfortunately, you’re going to have to get out a goniometer to do a good job.
An orthotic that tries to immobilize the joint in its fully pronated state is the object. That means the more rigid, the better it works. Talk to your lab about how to get an orthotic that is very rigid. I have on occasion added up to 1cm thick PMM re-inforcement under an acrylic device to get the rigidity.
If the patient truly has the coalition you described, you should have noticed that...
Editor's note: Dr. Phillips' extended-length can be read here.
02/01/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: The Use of Uloric vs. Allopurinol in the Management of Gout (David J Kaplan, DPM)
From: Jon Purdy, DPM
This forum is a great place for colleagues to assist each other in providing excellent patient care and practice management advice for diseases like gout. Because scope of practice differs from state to state, community standards and resources vary widely, and individual podiatrist comfort levels differ as well, it seems the degree of treatment should be left to the discretion of the individual podiatrist.
Since there is insufficient high-quality evidence that exists for recommending one therapy over another in the case of gout, some may be surprised to know that there are currently no guidelines for treatment. However, the American College of Rheumatology (ACR) has, as of December 2011, posted a preliminary set of guidelines...
Editor's note: Dr. Purdy's extended-length letter can be read here.
01/27/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: Achilles Tendon Problem (Geoffrey Bricker, DPM)
From: David Zuckerman, DPM, Todd Lamster, DPM
Achilles tendinois proximal to the insertion into the posterior calcaneus (watershed area) can be safety treated with ESWT. I have treated this very painful problem many times over a 12-year period. The results of this type of treatment were published by John Furia, MD "High-Energy Extracorporeal Shock Wave Therapy as a Treatment for Chronic Noninsertional Achilles Tendinopathy" Am J Sports Med March 2008 (36) 502-508.
If is very effective when the proper case is selected. If there is a tear, it must be elevated to see if treatment is possible. A tear isn't an automatic exclusion with ESWT. The degree,length of time present, as well as MRI evaluation must be taken into account. It is non-invasive, painless, and requires a single treatment in an office setting without the need for any local anesthetic.
David Zuckerman, DPM, Cherry Hill, NJ, footcare@comcast.net
I have recently treated a few patients successfully with platelet-rich plasma injections. My protocol was as follows: a PRP injection, followed by partial NWB and immobilization using a CAM walker, followed then with 2 weeks of PT. This cycle would be repeated a total of three times. I had one patient in his middle forties who gave up basketball entirely due to chronic Achilles tendinosis. I had to perform three injections in his left Achilles and one in his right. He also followed my protocol to the letter. Now, he is back to participating in tournaments and coaching a youth league. I strongly recommend PRP injection therapy.
Todd Lamster, DPM, Gilbert, AZ, tlamster@gmail.com
01/26/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: Achilles Tendon Problem (Geoffrey Bricker, DPM)
From: Richard I Polisner, DPM
Unfortunately, I have first-hand knowledge of Serapin injections for chronic Achilles tendon pain. I had pain for 6-9 months, which was not significantly helped by PT, ice, heel lift, or anti-inflammatories. I did continue playing basketball and tennis with pain. After researching the literature which talks about increased incidence of rupture, I finally had it injected with Serapin and a local anesthetic. There was immediate relief which lasted about 8 weeks until the tendon ruptured just proximal to the insertion. It has not been painful since the surgical repair.
Richard I Polisner, DPM, Ponte Vedra Beach, FL, rpolisner@hotmail.com
01/05/2012
RESPONSES / COMMENTS (CLINICAL) - PART 2
RE: Orthotic Therapy for Hallux Rigidus (Arthur Lukoff, DPM)
From: James Clough, DPM
I have seen no credible evidence that using a first ray cut-out in any form works. Whenever we do a forefoot cut-out, we do a cut-out to off-weight the metatarsal, not to promote plantarflexion. I find that a cut-out here, under the first metatarsal, destabilizes the foot, as the medial forefoot tripod arm is not stable and the foot pronates excessively through midstance and into active propulsion. The only two studies that I am aware of looking at this issue are from Canada. "Effectiveness of the Kinetic Wedge Foot Orthosis Modification to Reduce Relative Plantar Pressure", Rambarran, K.K., et al.,* showed a decrease in pressures under the first metatarsal head, not an increase. The same author, looking at gait posture, showed no improvements. The most reliable way to plantarflex the first metatarsal is to dorsiflex the hallux, via the Cluffy Wedge.
As far as shortening metatarsal osteotomies are concerned, I do not do these, as I believe they interfere with the function of the first ray. A cheilectomy will not adversely affect first ray function, and I believe is a better solution. After surgery, if the first MTPJ functions normally, the joint should be fine long-term, but re-establishing normal function of the joint, surgically or non-surgically, I believe, is critical to the success of any surgical intervention.
Disclaimer: I am the inventor of the Cluffy Wedge.
James Clough, DPM, Great Fall, MT, jclough@bridgemail.com
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