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12/27/2011
RESPONSES/COMMENTS (CLINICAL) - PART 3
RE: Orthotic Therapy For Hallux Rigidus (Elliot Udell, DPM)
From: Keith Gurnick, DPM
Can someone tell me the rationale behind this statement by Dr. Udell to treat symptomatic HR or HL. "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."
I do not understand how a non-rigid Morton's extension or padding under the hallux will alleviate 1st MPJ pain due to this condition. This includes items such as a Cluffy wedge. The philosophy that the padding under the big toe, or the wedge under an orthotic extension pushes up the hallux to dorsi-flex the 1st MPJ by allowing the 1st metatarsal to plantarflex in gait does not seem plausible. Would this not simply use up some of the limited available dorsi-flexion and further put pressure dorsally at the joint. To me, it is like the tail wagging the dog. How can this work?
I often pad or tape with a dancer's type pad to off-load the hallux and 1st metatarsal head by lifting up under 2-5 met heads, or when indicated, I make a custom orthotic with similar forefoot padding and extensions. Some people call this a "reverse Morton's extension," but I don't like that term. Any thoughts?
Keith Gurnick, DPM, Los Angeles, CA, keithgrnk@aol.com
Other messages in this thread:
09/11/2020
RESPONSES/COMMENTS (CLINICAL) - PART 3
From: Don Peacock, DPM, MS
I have performed numerous corrections on patients with transverse hammertoe deformities using both traditional and minimally invasive techniques taught by the Academy. In my experience, the MIS techniques are better and longer-lasting when compared to traditional procedures. We have hundreds of patients out for many years with continued rectus correction following digital transverse plane hammertoe deformity corrected by MIS techniques.
I do respectively disagree with my colleagues Drs. Nadal and Cohen and their requirement for metatarsal oseotomy. For patients that do not present with subluxed MPJ deformity, the metatarsal osteotomy is not necessary. Basing the technique on metatarsal length has never been proven to be a reliable indicator for metatarsal osteotomy. Here is a video showing correction of a severe transverse deformity without the use of a metatarsal osteotomy.
Don Peacock, DPM, MS, Whiteville, NC
06/25/2018
RESPONSES/COMMENTS (CLINICAL) - PART 3
From: Brian Kiel, DPM, Dave Williams, DPM
I have had good results using Topaz on the Achilles as well as plantar fascia. Over a period of time, I have devised a technique that works well.
Brian Kiel, DPM, Memphis, TN
Surgery may still be an option, and you do not have to transect the Achilles tendon for good results. O.A. Mercado, DPM made a series of surgical instructional DVDs entitled, “The Art of Surgery.” He has 2 specific DVDs dedicated to Haglund’s deformity and calcified tendo-Achilles. I recommend the series. He is a wonderful teacher.
Dave Williams, DPM, El Paso, TX
12/26/2016
RESPONSES/COMMENTS (CLINICAL) - PART 3
From: Dieter J Fellner, DPM
On the question of the shortening of the first metatarsal S/P osteotomy: this is really not an issue, and might often be a desirable effect. With an osteotomy to decompress and reduce the mechanical forces on the joint, this results in the 'buckling' and displacement of the 1st MTPJ.
There are two important caveats:
First, the sesamoid apparatus must be positioned in the correct anatomical alignment in relation to the first metatarsal head. There is very little tolerance to this rule, if a surgeon wants to optimize on outcome, a flexible...
Editor's note: Dr. Fellner's extended-length letter can be read here.
12/23/2016
RESPONSES/COMMENTS (CLINICAL) - PART 3
From: Don Peacock, DPM
I agree with Dr. Gurnick's conclusion with regard to the necessity of weight-bearing lateral x-rays for appropriate assessment. In my original post, I included both AP and lateral x-rays pre and post. Only the AP x-rays were published.
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Pre- and post-op lateral x-rays |
This patient had a relatively small IM angle and our differing measurements may reflect some differences in how we are viewing the IM angle. Our measurements are not drastically different, and as Dr. Gurnick states, good correction is noted. Also both of us are getting improved...
Editor's note: Dr. Peacock's extended-length letter can be read here.
08/28/2015
RESPONSES/COMMENTS (CLINICAL) - PART 3B
From: Robert D. Phillips, DPM
I note the never-ending debate on the value of pre-fabricated orthotics vs. custom-made orthotics, with everyone holding dear to their position by citing their favorite research article. This is indeed a most superficial debate and shows failure of those who engage in it to dig down into basic biomechanics and basic mechanical science. If anyone who really studies these basic sciences uses a term such as “moment of inertia” or “stress-strain curve”, or even “direction cosines”, we find a vast majority of clinicians who shut the mental blinders, believing that they don’t need to understand math or physics – after all they are “real surgeons.”
While I could make a whole lecture on the subject of why pre-fab orthotics work or don’t work, I would like to make just a few points in this correspondence. ...
Editor's note: Dr. Phillips' extended-length letter can be read here.
09/10/2014
RESPONSES/COMMENTS (CLINICAL) - PART 3
From: Neil Levin, DPM
I have been experiencing similar issues to Dr. Borreggine's more recently, and I have been in practice for more than 30 years. I believe that our patients are becoming more non-compliant with ambulation, causing more swelling. We lead busier lives, and despite all of our instructions, patients tend to maintain as much of their pre-surgical activity level as they can. I believe your issues are not dressing-related.
03/24/2014
RESPONSES/COMMENTS (CLINICAL) - PART 3
From: Elliot Udell, DPM
Thus far, the only ones who responded to Len Levy's concerns about laser therapy for onychomycosis were those who are providers of laser equipment. Dr. Levy quoted a paper published in a significant dermatology journal. This paper was picked up and quoted in a widely read newspaper and is available online. I do not use lasers to treat onychomycosis in my practice, but would love to hear from those colleagues who do use it whether the article quoted by Dr. Levy is correct or incorrect.
A patient who presented to my office today, read the article in the NY Times and thinks that podiatrists who use lasers to treat mycotic nails are crooks. She is livid because she paid a colleague of ours $900 for the treatment, and it did not help her. I am willing to give this fellow podiatrist the benefit of the doubt. Not every treatment works every time.
Perhaps some of you who have used this modality on many patients can enter this discussion and let us know your experience with lasers for the treatment of mycotic nails.
03/10/2014
RESPONSES/COMMENTS (CLINICAL) - PART 3
RE: Using Nitropaste to Increase Blood Flow
From: Wm. Barry Turner, BSN, DPM
In this time of studies and verifiable proof of effectiveness, I can only offer what I have seen.
I once used nitropaste on a patient, and tested perfusion with a laser Doppler. The digital perfusion increased 300% in five minutes. When I applied nitroglycerin paste as an RN (treating acute MI), I would apply the paste to a piece of paper and tape the paper to the person's chest. The PDR distinctly states...
Editor's note: Dr. Turner's extended-length letter can be read here,
03/08/2014
RESPONSES/COMMENTS (CLINICAL) - PART 3
From: Robert Bijak, DPM
In my opinion, this result is not satisfactory and will lead to difficulties later on. I believe a simple amputation would have provided a better cosmetic and functional result.
12/14/2013
RESPONSES/COMMENTS (CLINICAL) - PART 3
From: Martin V. Sloan, DPM
I'd be reluctant to suggest autism as a diagnosis to the parents of this toe walker. If a thorough physical examination reveals no abnormalities (neurologically sound, no evidence of musculoskeletal problems, etc.), it might be simply a behavioral problem that the child outgrows. I was a toe walker until about age 11, and I tended to keep my mouth shut because to speak out of turn might result in a whack to the head. I've encountered patients like this, and have recommended stretches and shoe modifications. I followed them closely. Eventually, they "outgrew" the behavior.
12/12/2013
RESPONSES/COMMENTS (CLINICAL) - PART 3
From: Larry Huppin, DPM
When addressing the mechanical aspects for this patient, it is important to note that both pressure and friction play a role in callus formation. Pressure can be decreased most effectively by using an orthosis that conforms very close to the arch of the foot in order to transfer pressure from the areas of callus formation at the metatarsal heads and heel to the arch. For the forefoot calluses, a Poron metatarsal pad or metatarsal bar on top of the orthosis will further act to transfer pressure from the met heads to the area of the metatarsal neck and shaft. Rocker-soled shoes can also decrease localized metatarsal head and heel pressure depending on the location of the rocker.
The orthosis alone, however, will have a limited role in decreasing friction. Using socks with a lower coefficient of friction and that wick moisture (acrylic rather than cotton) will help decrease friction. Decreasing moisture with the use of antiperspirants can also help. A more effective method to decrease friction is to apply an ultra-low coefficient material such as a polytetrafluoroethylene (PTFE) patch to the orthosis topcover at the location of callus formation. A PTFE patch has a coefficient of friction of .16, compared to between .5 and .9 for common topcover materials such as leather, Spenco®, and polyethylene forms such as EVA. In addition, PTFE is the only material that can be applied to a shoe or orthosis which will not have an increased coefficient of friction when it becomes wet. By reducing the coefficient of friction, local skin trauma is reduced.
Disclosure: I am the medical director at ProLab Orthotics; a manufacturer of foot orthoses and distributer of the PTFE Patch™
11/04/2013
RESPONSES/COMMENTS (CLINICAL) - PART 3
RE: PRP Therapy for Plantar Plate Tears (Charles Morelli, DPM)
From: Barry Mullen, DPM
I respectfully disagree with Dr. Morelli utilizing the following rationale and philosophical approach to foot surgery.
What´s interesting about plantar plate tears is that, for many years as a profession, we didn't appreciate this pathology. Even today, I see many cases misdiagnosed as neuromas because "burning" pain is often ascribed as a pain descriptor and when the tear is eccentrically located, the 2nd toe will drift, often medially, giving a pseudo Sullivan sign associated with space occupying soft tissue masses in the web space. For years, many....
Editor's note: Dr. Mullen's extended-length letter can be read here.
11/02/2013
RESPONSES/COMMENTS (CLINICAL) - PART 3
From: Barry Mullen, DPM
I agree 100% with Dr. Sullivan. Most plantar plate tears I have seen have associated excessively long 2nd metatarsals. Hallux limitus with metatarsus primus elevatus is often present as well. The altered 1st ray mechanics, combined with the excessive 2nd MTP ground reactive forces created by the increaased metatarsal protrusion angle cause the plantar plate tearing, or degeneration. If an off-loading orthotic didn´t work as a primary conservative therapy (you must diagnose and treat this condition very early to expect an orthotic to work), it is highly unlikely PRP would enhance the result. For this particular pathology, PRP should only be considered as an adjunct therapy to a complete plantar plate surgical repair.
Arthrex´s Scorpian suture, as Dr. Sullivan alluded to, makes this repair very managable from the dorsum of the foot. There is a bit of a learning curve regarding the technique, but once mastered, one can expect to achieve consistently excellent results.
10/31/2013
RESPONSES/COMMENTS (CLINICAL) - PART 3
From: Tip Sullivan, DPM
I must not understand this PRP therapy line of discussion. As far as I know, platelet rich plasma (in its several forms) is used to enhance healing. If there is a physical tear in a structure and that structure’s length is physically altered, PRP will not lengthen or shorten it and straighten a toe. I suppose you could use it as an adjunct to surgical repair if you could justify the expense in some extraordinary case. A note from experience: Arthrex sells an angulated suture passing instrument that is (almost) worth the expense due to its reduction of dissection required.
09/25/2013
RESPONSES/COMMENTS (CLINICAL) - PART 3
RE: Unstable Scar
From: Shari Lewis Kaminsky, DPM, Bret M. Ribotsky, DPM
I have seen this in a case of a Achilles tendon tear and over-lengthening of the Achilles tendon. He ended up with a patellar tendon weight-bearing device, and it finally healed. I also did a FHL tenotomy because of a hallux malleus, and he healed quite rapidly after that.
Can we agree that the previous treatments did not go as planned; thus, it's time to step back and ask a lot of questions and get a very good medical history. Review the blood work, check the radiology tests, do gait analysis, etc. What we know is that the patient has diabetes with multiple amputations and Achilles tenotomies. The first thing that "pops" in my mind is "What does the other foot look like?" I want to know if this patient has a revasculized leg. I think we all need to gather more information.
12/26/2012
RESPONSES/COMMENTS (CLINICAL) - PART 3
RE: Footwear Modifications S/P 4th and 5th Ray Resections (Jeffrey Kass, DPM)
From: Robert Schwartz, CPed
At Eneslow, the following is our primary pedorthic protocol. Shoe modifications usually include 20+ degree midfoot semi-rigid rocker with apex under Lisfranc’s joint, fulcrum angle matching the line of progression in gait. It is designed to transfer pressure and reduce impact forces. This may include lateral flare and heel rocker to provide a broader base of support.
Orthotics can include forefoot filler to reduce abductory forces while protecting the amputation site; combination of memory and thermoplastic foams under remaining forefoot to create a plantigrade foot from heel contact through propulsion. Footwear includes extended counters, high tops to help control foot movement (shear/friction) within the shoe. The contralateral side should be expected to carry a disproportionate share of the load requiring complementary modifications, and orthotics.
Robert Schwartz, CPed, NY, NY, rss@eneslow.com
08/17/2012
RESPONSES/COMMENTS (CLINICAL) - PART 3
RE: Verruca Treatment in an Immunocompromised Patient
From: Catherine Wu, DPM
I would like to clarify the previous post that the diagnosis of verruca vulgaris has been confirmed by shave biopsy. The lesion is painful and there is no hyperhydrosis present. I have treated him for less than 6 months without much improvement. My medical supplier does not carry Canthranone. I will try to convince the patient to take some time off and proceed to either laser or surgical excision. Thanks for all the replies and comments.
Catherine Wu, DPM, ccwu68@yahoo.com
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