08/27/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 2
RE: I Want to Work as a Podiatrist (Juliet Burk, DPM)
From: Steven Gershman, DPM
Amen to Dr. Burk. A completely well-reasoned argument about how podiatry has lost its way. If you want to be just a foot and ankle surgeon, be an orthopedist. Three-year residencies create orthopedist wannabees.
Podiatry is the total care of the foot and ankle, including dermatology, neurology, medicine, endocrinology, biomechanics, surgery, and general palliative care. It was never meant to be just surgery. And yes, women often do have to deal with different pressures than men.
Steven Gershman, DPM, Auburn, ME, obsidianom@aol.com
08/19/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 2B
RE: Severe Heel Pain After Plantar Fasciotomy (Mark Aldrich, DPM)
From: Michael Rosenblatt, DPM
Whenever you have a patient with severe localized pain, you might find benefit in looking for a cause that is not necessarily inflammation-related, like nerve damage or a conduction defect. Patients like that benefit from nerve conduction studies, which you can then have a physical medicine consultant read and consider. We always worry about treating these patients with any form of narcotic because they are highly likely to become acclimatized and possibly addicted to them. The irony of narcotic analgesic therapy for chronic pain is that the pain itself becomes how the addiction is expressed.
This is why some pain specialists use...
Editor's note: Dr. Rosenblatt's extended-length letter can be read here.
08/19/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 2A
RE: Severe Heel Pain After Plantar Fasciotomy (Mark Aldrich, DPM)
From: Peter Bregman, DPM
In order to rule out or rule in nerve pathology, I recommend doing a diagnostic block using no more than one cc of lidocaine plain in the medial calcaneal nerve and lateral plantar nerve separately. This may or may not be assisted by ultrasound. You can also look for a Tinel's sign with both these nerves as well. This will help make the diagnosis of a nerve problem versus something else.
Peter Bregman, DPM, Las Vegas, NV, drbregman@gmail.com
08/17/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 2
RE: Popliteal Block for Forefoot Surgery (Tip Sullivan, DPM)
From: Philip McKinney, DPM
I routinely use a posterior tibial block, followed by a field block of the surgical area for forefoot surgery. If doing a rearfoot procedure, I do a common peroneal block with a surgical site field block. If the case involves the ankle, or an Achilles tendon location, then I use the popliteal block with a surgical field block.
Philip McKinney, DPM, Eugene, OR, opodiatry@oregonpodiatry.net
08/16/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 2
RE: Staged Procedures for Digital Deformities (Ivar Roth, DPM, MPH)
From: Michael J Marcus, DPM, Kevin A. Kirby, DPM
If a patient has mild to moderate deformities of the forefoot, for ex. bilateral HAV or HT 4 and 5, I will in many cases give the patient an option of doing one foot or both at the same setting. However, this is also based on other factors. These include if they have household assistance, job circumstances, other responsibilities, as well as the patient's general medical health. However, I do agree with Dr. Roth that bilateral surgery, when possible, is truly cost-efficient.
Obviously, if a patient has severe deformities that would require NWB, then a unilateral surgery would be favored. I do not find that one's complication rate is any greater performing bilat. vs unilat. procedures. Many orthopedic surgeons I know frequently perform bilat. TKAs. Lastly, staging procedures in an individual foot is sometimes necessary in DM reconstructions and severe deformity corrections such as adult talipes equino varus; also, in cases that involve complex rearfoot reconstruction as well as forefoot. However, I find it unethical when I hear members of our associations recommending doing the HAV in one setting, and the 2nd met and HT in another.
Michael J Marcus, DPM, Montebello/Irvine CA, ftmed@aol.com
I find the suggestion that podiatrists who recommend unilateral versus bilateral surgical procedures do it "for one purpose only, and that is to make more money" quite insulting. I routinely recommend unilateral surgical procedures versus bilateral surgical procedures to my patients, when possible. The biomechanics of recommending unilateral procedures in the bipedal human is quite clear. With unilateral surgical procedures, the bipedal human has only half of their weight-bearing appendages compromised. With bilateral surgical procedures, the bipedal human has all of their weight-bearing appendages compromised. I think that any intelligent and ethical podiatrist would understand this basic biomechanical concept and use this knowledge to design the best surgical, or non-surgical, treatments for their patients, regardless of the reimbursements expected for those treatments.
Kevin A. Kirby, DPM, Sacramento, CA, kevinakirby@comcast.net
08/15/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 2
RE: Severe Heel Pain After Plantar Fasciotomy (Mark Aldrich, DPM)
From: Mitchell Wachtel, DPM, Charles Morelli, DPM, David A. Stoller, DPM
A gauntlet AFO may be the best option. This should be worn a minimum of a year.
Mitchell Wachtel, DPM, North Andover, MA, jacqitch@comcast.net
Get a neuro consult and rule out entrapment of the lateral plantar nerve or any nerve damage caused by the procedure. Consider radiofrequency treatment if the neuro consult is negative.
Charles Morelli, DPM, Mamaroneck, NY, podiodoc@gmail.com
Your patient might have a subluxed cuboid. Take lateral x-rays of both right and left feet to evaluate the subtalar joint and cuboid joint position. The symptomatic foot might have a different position than the other one, which might indicate a subluxation. Then apply distal distraction, reducing subluxation. Follow up with a post-reduction x-ray to evaluate the new position.
David A. Stoller, DPM, Mission Viejo, CA, david@missionviejofootcare.com
08/03/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 2
RE: Cyclist with Bilateral Forefoot Pain (Mark Aldrich, DPM)
From: Robert Scott Steinberg, DPM, Tip Sullivan, DPM
What you describe is a very common problem for cyclists. Though he has a negative Mulder's sign, he is most likely still suffering from neuritis, and though he has a high quality cycling shoe, if it is a road shoe, it is narrow. To begin treatment, place met pads on the shoe's insoles, and have him go for a ride. If they help, next do a biomechanical exam and order an orthotic appropriate for the shoe he is wearing. If they are road shoes, there isn't much room and they are narrow. If that is the case, send a cast to JSB Orthotic Lab in Englewood, FL, and write for a thin TL2100, with met pads, no TL2100 under the heel, full length top cover with 1/16" STS extensions. This is the cycling orthotic I and JSB's owner, Scott Becker, designed a number of years ago. More questions? Call me: 847-885-8806
Robert Scott Steinberg, DPM, Schaumburg, IL, Doc@FootSportsDoc.com
You have described typical “hot foot” described by many cyclists, and in the literature. I have found the following to be as effective:
Use the widest shoe as possible— you can take the shoe to a shoe repairman and have slits put in the forefoot. First, try canting the shoe with a material placed between the shoe and the cleat. Second, try in-shoe forefoot posting. I have actually made full-length graphite orthoses from heel to toe with intrinsic and extrinsic posts. You might suggest pedaling technique change - increase the upstroke force.
This is a problem that there is no formula for. One can certainly use the principles of a very precise biomechanical exam to help, but in my experience, this is a problem that requires multiple tweaks. Another suggestion is to video him on a stationary set-up, so you can slow it down and make adjustments. After further review of symptoms, I also suggest consideration of “functional” tarsal tunnel which can also be the cause of hot foot and would require a slightly different biomechanical approach.
Tip Sullivan, DPM, Jackson, MS, tsdefeet@msfootcenter.net
07/17/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 2
RE: Interpositional Arthroplasty (David Secord, DPM)
From: Palmer Branch, DPM
I also echo the recommendation of Dr. Secord about the use of any interpositional acellular dermal matrix graft for resurfacing the first metatarsophalangeal head. It precludes the potential problems of donor site defects from harvesting local or remote soft tissues. I have also used a similar technique for lesser metatarsophalangeal joints (e.g. after Freiberg's infarction).
In the article referenced by Dr. Secord, I found a similar (same?) article below from the same group referenced in Foot and Ankle International. This article has nice...
Editor's note: Dr. Branch's extended-length letter can be read here.
07/16/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 2
RE: Interpositional Arthroplasty (Greg Caringi, DPM)
From: David Secord, DPM
I recommend the following article: Techniques in Foot And Ankle Surgery 5(4}:257- 265, 2006. A Soft-Tissue Interpositional Arthroplasty Technique of the First Metatarsophalangeal Joint for the Treatment of Advanced Hallux Rigidus Using a Human Acellular Dermal Regenerative Tissue Matrix. Gregory C. Berlet, MD , Christopher F. Hyer, DPM, Thomas H. Lee, MD, and Terrence M. Philbin, DO, Orthopedic Foot and Ankle Center, Columbus, OH
David Secord, DPM, Corpus Christi, TX, ledocdave@hotmail.com
06/17/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 2C
RE: Fissuring Under 4th and 5th Digits
From: Lloyd Nesbitt, DPM
I’d say that this is tinea pedis that should clear up in a few days with the use of Loprox b.i.d. (I find it to be more effective than Lamisil cream). Fissuring under the base of the 5th toe is common. It sometimes can occur after wearing shoes with no socks after one day.
I can’t say that I blame the 19 year old girl for not wanting surgical treatment of her syndactylized toes. A lot of women have this and aren’t concerned. For example, my wife and 26 year old daughter both have partial syndactylism of two of their toes and have never been the least bit bothered by it.
Lloyd Nesbitt, DPM, Toronto, Ont, Canada, lloydn@rogers.com
06/17/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 2A
RE: Fissuring Under 4th and 5th Digits
From: Barry Mullen, DPM
From the brief history given, the congenital issue is likely a coincidence for my initial thought is infectious etiology, not mechanical/strutural. Dermatophytes and Candida are notorious for causing interdigital fissuring, especially between 4th toe webs, toe creases, especially in moist environments, i.e. the patient's swimming history. Included in your patient's history is a 2-3 time/year recurrence, likely representing next generation spore germination and re-start of the infectious process. If it were a mechanical etiology, it would likely be constant all year round.
Consider empirically starting your patient on OTC bid topical fungicides, then switching to a broad spectrum Rx if no response in 3 weeks. Ensure that Rx covers Candida. If still no response, take a shave biopsy and submit for analysis as erythrasma and white psoriasis can also present this way. Pending biopsy result, if infectious, yet unresponsive to appropriate topical agents, you may also need to consider an oral agent, particularly for recurrent/resistant cases. If you want to initially avoid the minor surgery, a Wood's light may shed light on the etiology (no pun intended). Once infectious etiology is ruled in, then also follow through with patient education on the benefit of consistent shoe sanitizing, as well as the various hygiene adjustments your patient can undertake that protects toe creases from additional exposure.
Barry Mullen, DPM, Hackettstown, NJ, yazy630@aol.com
05/27/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 2
RE: Fluoroquinolone Toxicity (David Secord, DPM)
From: Robert Kornfeld, DPM
Dr. Secord wants "proof" that what I am asserting is supported by the literature. In fact, there is no paucity of literature regarding flouroquinolone toxicity syndrome. If you have not heard of fluoroquinolone toxicity syndrome, I suggest you do your own literature search as soon as possible. The question that always needs to be answered is why do these severe reactions only affect the people that they do. That is where the genetic research is applicable and is beginning to answer many questions.
In terms of the SNPs and their relationship to this toxicity syndrome, this is all emerging science and...
Editor's note: Dr. Kornfeld's extended-length letter can be read here.
05/17/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 2
RE: Painful Bunion in a 12 Year Old
From: Keith L. Gurnick, DPM
Additional non-surgical treatment should be attempted first due to her youth. Make her new properly-designed custom orthotics to stabilize her foot and suggest proper shoes. See if you can improve her symptoms, and allow more growth and maturity for at least 4 years.
She is still a bit young for bunion surgery unless good conservative care is tried and failed. An "aching" joint on an initial presenting visit and a diagnosis of bunion should not automatically mean...
Editor's note: Dr. Gurnick's extended-length letter can be read here.
05/09/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 2B
RE: Chronic 1st MPJ Pain (Charles Morelli, DPM)
From: Don Peacock, DPM
I have to respectfully disagree with Dr. Morelli regarding this particular case. I too am a fan of the Cotton procedure. It is a great way to stabilize the medial column and achieve plantarflexion of the first ray.
Addressing of the gastrocnemius equinus will give you plantar flexion of the first ray as well. When I first heard of this, I was very skeptical myself. The reason plantarflexion of the first ray occurs after a gastrocnemius recession is because...
Editor's note: Dr. Peacock's extended-length letter can be read here.
05/09/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 2A
RE: Chronic 1st MPJ Pain (Don Peacock, DPM)
From; Scott Hughes, DPM
I assume Dr. Peacock shared his pre- and post-op x-rays to show the success of his MIS technique. I think most of us would agree that decompressing the 1st MPJ by shortening and plantarflexing the 1st met head is desirable for hallux limitus. However, the osteotomy, besides being inherently unstable and an elevatus waiting to happen, is oriented to create lengthening. Also, the osteotomy creates a plantar shelf directly above the sesamoids.
I am happy to hear the patient is pain-free, but when I look at this case, my thought is 'better lucky than good' rather than MIS is a viable alternative.
Scott Hughes, DPM, Monroe, MI, dr.hughes@comcast.net
05/04/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 2
RE: Dorsiflexed Hallux (Kel Sherkin, DPM)
From: Randall Brower, DPM
This forefoot is offering the patient no biomechanical help. A transmetatarsal amputation gives the patient the quickest return to function. Sometimes, we get tunnel vision trying to save toes without looking at the big picture, what are these toes doing FOR the patient? Previous osteomyelitis should warrant a definitive procedure. TMA with TAL or EGR.
Randall Brower, DPM, Avondale, AZ, footdoctor33@yahoo.com
05/01/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 2
RE: Non-Specific Bone Marrow Edema Syndrome?
From: Howard J. Bonenberger, DPM
It is difficult to tell from one MRI slice, but it looks like the subtalar joint line is angled relative to the tibia-talar joint line, and that there are signal and morphology changes at the sustentaculum tali. Has tarsal coalition been considered? Additional slices posted by the podiatrist could be helpful. Certainly, the compressive forces brought on by a coalition could lead to pain and marrow edema in the associated bones. Are there other physical findings such as peroneal spasm, limited ROM of the STJ? Is the halo sign seen on the lateral x-ray?
I had a similar case with a late-teen female athlete who had a fibrous, extra-articular coalition at the posterior-medial STJ. Her diagnosis took a very long time as her symptoms and the diagnostic studies were confusing to the multiple specialists who evaluated her. Eventually, she underwent a STJ fusion and has done well.
Howard J. Bonenberger, DPM, Nashua, NH, howardbon@aol.com
04/27/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 2B
RE: Non-Specific Bone Marrow Edema Syndrome
From: Patrick J. Nunan, DPM, Michael M. Rosenblatt, DPM
I had a similar case in a 15 year old softball player. The MRI was read initially by radiologist at a children's hospital and then again by an independent MRI radiologist, both who called it multiple stress fractures. She was initially seen by a Med/Peds specialist who ruled out most metabolic diseases. Her Vitamin D levels were extremely low, especially for her age. She was placed on a Vitamin D regimen by her PCP. Orthotics were made to reduce biomechanical stresses. She was immobilized in a CAM walker as well. Follow-up MRI showed improvement. She was able to return to normal activities without pain, but did not return to competitive softball.
Patrick J. Nunan, DPM, Huntington, WV, pjndpmrun@aol.com
In any young person who has bone marrow changes, it is important to consider Gaucher's disease, which occurs often in Ashkenazy Jews, but can also occur in other populations. You might more likely see avascular necrosis of the femoral heads as well as hepatospenomegaly. A low platelet count would also be expected.
A hematologist would do a bone marrow biopsy to look for Gaucher's cells. This is not a typical presentation of the disease, but a bone marrow biopsy is the next step.
Michael M. Rosenblatt, DPM, San Jose, CA, Rosey1@prodigy.net
04/27/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 2A
RE: Non-Specific Bone Marrow Edema Syndrome
From: Pat Caputo, DPM
The radiologist might be spot on. "Non-specific bone marrow edema" is also called transient or migratory regional osteoporosis. Certainly, her age group is not discussed in the literature, so a pediatric rheumatology or better yet endocrine consult is very highly suggested, especially in the absence of trauma. In the meantime, I would treat it like a Sudeck's atrophy or early AVN; and tell her it may take months, which is why the radiologist said to follow up with an MRI in 3 months. When the patchy MR presentation resolves, so do the symptoms. She is at risk for fracture in the short term, in addition to pain.
I had "bone marrow edema" in my early 40s in one hip and then the other, and 10 years later in one shoulder and then the other. I did a fair amount of research which included anecdotal discussions with some prominent endocrinologists from Johns Hopkins and UPENN as well as a prominent musculo-skeletal radiologist from Jefferson Med in Philadelphia. I was treated in the shoulders with IV Aredia. I'm not sure if it helped, as it still took months to run its course. It is more common in middle age men and pregnant women, so again I would definitely do a diagnostic work-up on the teenage girl.
Pat Caputo, DPM, Holmdel, NJ, capstops@aol.com
04/06/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 2B
RE: Recalcitrant Heel Pain (Loren J Miller, DPM)
From: Don Peacock, DPM
Unfortunately, we’ve all had this type of patient and it can seem like no treatment options are left. However, in my experience, most patients who have not responded to appropriate treatments for heel pain have gastrocnemius equinus. Check to see if he has equinus by performing the Silfverskoid test. If he has gastrocnemius equinus, then you will need to address this. This can be done minimally invasively via endoscopic gastrocnemius recession. It is important to determine whether or not he has a true cavus or normal foot type. It sounds like he may have some degree of pseudo-equinus that is compensated.
This foot type can respond negatively to plantar heel surgery, but may respond very well to a gastrocnemius recession. In conjunction with the gastrocnemius recession, consider ablation of the calcaneal nerve branch. The reports have been very favorable for nerve ablation for correction of recalcitrant heel pain. Definitely address the equinus deformity, if present. These options are minimally invasive and may be more appealing for someone who has already gone through extensive treatment.
Don Peacock, DPM, Whiteville, NC, peacockdpm@gmail.com
04/05/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 2
RE: Nitroglycerin Paste vs. Topical Procardia (Wm. Barry Turner, BSN, DPM)
From: Simon Young, DPM
I heard about this treatment when I was in podiatry school (1978). Is this another anecdotal treatment? Are ABIs/PVRs being done pre-treatment? If it is an ischemic wound and blood is restricted to the foot, how is vasodilating the capillaries helping with blood flow? What about PT blocks? Shouldn't they be more beneficial. Will these topicals work if blood flow is restricted to the ankle? Is there any system absorption of the nitroglycerine paste which could impact the cardiovascular system?
Simon Young, DPM, NY, NY, simonyoung@juno.com
04/04/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 2B
RE: Post-op Varus (Joshua Kaye, DPM)
From: Cosimo A. Ricciardi, DPM
From the x-rays that Dr. Kaye has provided, I disagree that a bone graft is necessary for fusion. That implant is doomed. An arthrodesis of the first MPJ, shortening of the second metatarsal, arthrodesis of the PIPJ, and tightening the lateral MPJ capsule should provide a much more functional and cosmetic result.
Cosimo A. Ricciardi, DPM, Ft. Walton Beach, FL, basewedge@yahoo.com
04/04/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 2A
RE: Post-op Varus (Joshua Kaye, DPM)
From: Tip Sullivan, DPM
These feet always seem to be difficult to get right. I have adopted a simple attitude which I am sure will illicit different opinions. When in doubt—fuse it. I would also have corrected the transverse plane problem of the lesser digits in some fashion. To look at this problem as the lesser digits pushing the hallux back into varus is way too simplistic.
This is an issue that is based in biomechanics, and until you understand the biomechanics behind it, you are going to have trouble with surgical outcomes—especially long-term. This deformity is based in the mid or rear foot, if not higher. The real difficult thing is addressing this component in a 70+ year old person and keeping the morbidity as low as possible. As usual, it goes back to the risk/benefit ratio.
Tip Sullivan, DPM, Jackson, MS, tsdefeet@MSfootcenter.net
04/03/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 2
RE: Night-Time Pruritus in Pregnant Patient (Christine Dalrymple, DPM)
From: Juliet Burk, DPM
She needs to be checked for intrahepatic cholestasis of pregnancy. While rare, it causes serious late-term infant mortality (stillbirths) and stress. It is exacerbated by heat which may be why she gets it at night if her covers are warm. It is caused by bile salt deposition under the skin of the hands and feet due a reaction by the liver to the high levels of estrogen associated with pregnancy and is not associated with a rash. Exercise can make symptoms worse (again due to increased skin heat). It progressively worsens the longer the pregnancy. It is found by a simple blood test to determine if the bile salts are elevated. If positive, she needs an experienced OB/GYN to follow her as her pregnancy would be classified as high risk. The good news is that ursodiol can completely relieve the symptoms, but that should be prescribed by her OB/Gyn.
Juliet Burk, DPM, Muskogee, OK, juliet-burk@cherokee.org
03/22/2013
RESPONSES / COMMENTS - (CLINICAL) - PART 2
RE: Forefoot Surgery on an 84 Year Old (Joseph Borreggine, DPM)
From: Tip Sullivan, DPM, Ed Cohen, DPM
The surgical plan you have sounds rational. One other thought might be a plan to simply address the chief complaint on this 80+ y/o and improve the other issues (other lesser digits and hallux varus) with some more conservative ideas. There is one saying that I have found true, especially in the elderly: The enemy of good is perfect.
Tip Sullivan, DPM, Jackson, MS, tsdefeet@MSfootcenter.net
I was very surprised to read some of the replies to this query. I expected to read about fixated metatarsal osteotomies and fusions of lesser toes, but I really didn't expect podiatrists advocating amputation of the second toe and a fusion of the first MPJ, a non-painful joint.
I have a large geriatric practice and I often encounter similar feet. The hallux varus was what I would consider to be...
Editor's Note: Dr. Cohen's extended-length letter can be read here.
