05/20/2024
QUERIES (CLINICAL)
Query: Men’s Shoe Recommendations Post-Achilles Tendon Rupture
What are the best men’s shoe recommendations post-Achilles tendon rupture and repair?
David Cohen, DPM, Pikesville, MD
03/21/2024
QUERIES (CLINICAL)
Query: Podiatrist with Carpal Tunnel Syndrome
I have recently been diagnosed with carpal tunnel syndrome. A recent post mentioned that radial pulse therapy has been used to successfully treat trigger finger. Has anyone had experience in using this for treatment of carpal tunnel syndrome?
Name Withheld
03/12/2024
QUERIES (CLINICAL)
Query: Recalcitrant Case of Posterior Tibial Tendonitis
I’m wondering if anyone has treated a recalcitrant case of posterior tibial tendonitis (found on MRI) of the slip to the medial cuneiform. It is tender just under the medial cuneiform. The patient wears HOKA shoes and custom orthotics, and was in a boot and using a knee scooter non-weight-bearing for 4 weeks. The main posterior tibial tendon is non-tender and the patient can do bilateral; heel raises without pain, but single leg heel raises hurt after a certain number of lifts. The patient is also seeing a physical therapist.
PM News Subscriber
03/11/2024
QUERIES (CLINICAL)
Query: Cocktails for DPN
I’m interested to read about the individual cocktails that DPMs use for diabetic peripheral neuropathy (DPN).
Rich Willner, DPM, Kenner, LA
02/29/2024
QUERIES (CLINICAL)
Query: Phenytoin 10% Topical Gel for Neuropathic Pain?
Has anyone ever used or prescribed phenytoin 10% topical gel for neuropathic pain?
Jeffrey Klirsfeld, DPM, Levittown, NY
02/09/2024
QUERIES (CLINICAL)
Query: Peripheral Neuropathy Without Vibratory Deficits
I have had several patients recently who complain about tingling and burning of their feet and they are not diabetic, nor have a hereditary form of neuropathy, nor are they alcoholic. They don't complain of lancinating pain and they can get to sleep without much difficulty. They feel the tuning fork in all areas of their feet and their reflexes are brisk.
I am asking for some interpretation of these findings. Am I missing something, or is this a pre-neuropathy state and vibratory sense will soon degrade?
Robert D Teitelbaum, DPM, Naples, FL
01/17/2024
QUERIES (CLINICAL)
Query: Punctate Keratotic Lesions
A 65 year old male has suffered from multiple punctate keratotic growths in the arches of both feet for 20 years. He denies any family history of this or arsenic exposure. He has no medical conditions currently and doesn't take any medication. Most of the lesions are nucleated and debridement provides some temporary pain relief.
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Punctate Keratotic Lesions |
He had cryotherapy in the past which did not resolve them and his dermatologist says they are "caused by his shoes". Any thoughts on diagnosis/treatment would be appreciated.
01/16/2024
QUERIES (CLINICAL)
Query: Longitudinal Lines in Fingernails
A patient happened to show me her hand and asked me to comment on her fingernails. I was wondering if any of my esteemed colleagues can chime in with any thoughts.
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Longitudinal Lines in Fingernails |
The patient is female, 50 with no medical issues, NKDA. She does wear nail polish, and is a non-smoker.
12/07/2023
QUERIES (CLINICAL)
Query: Chronic Leg/Foot Pain
A 49 year old white male presented with pain from his knees down, with a duration 20 years. He reports that it hurts worse when walking but there's also pain at rest, which keeps him up. The pain is described as aching with no numbness, tingling, or other neurologic complaints. He had shots done in his foot for an unknown diagnosis 20 years ago and they hurt so bad he did not seek treatment until this year. PMH is non-contributory, he is not on any meds. His PCP sent him to a neurologist. They did an MRI of the lumbar spine, an arterial Doppler, and lab work for CBC,CPK, magnesium SH, and vitamin B 12. All testing was normal. They tried an NCV-EMG but he could not tolerate the testing.
Vascular and derm. exams are unremarkable. A neuro exam revealed intact light touch and vibratory sense and DTRs and muscle strength 5/5. A gait exam revealed mild pes planus but an antalgic gait. He walks like an old man with arthritis. Pain is poorly localized throughout feet and legs. I ordered x-rays of the feet, but am unsure what the diagnosis is and would appreciate any insights. I leaned toward small fiber neuropathy as a diagnosis, but put him on gabapentin, and somehow I feel something is being missed.
10/16/2023
QUERIES (CLINICAL)
Query: Platelet-Rich Plasma
Has anyone had experience with platelet-rich plasma injections being used to heal a plantar fascia tear?
Deardre Nadel, DPM, Bronx, NY
09/11/2023
QUERIES (CLINICAL)
Query: Skyrizi for the Treatment of Pedal Psoriasis
Does anyone use Skyrizi for the treatment of pedal psoriasis? All day long on television, they are advertising Skyrizi and at least one other drug for the treatment of plaque psoriasis. These pharmaceuticals are administered via infusion. Has anyone used them to treat psoriasis affecting the feet? Some of my patients who have psoriatic plaques have gone to dermatologists who have used these drugs and have done extremely well. I am wondering if we should be using them if the plaques are on the patient's feet.
Elliot Udell, DPM, Hicksville, NY
09/08/2023
QUERIES (CLINICAL)
Query: Veno Lymphatic Malformation
A 10 year old figure skater has been experiencing general pain in her arch and ankle. X-rays were unremarkable with the exception of possible Sever's disease. An MRI was then done and an area was found on the bottom of her foot by her heel. The report came back as a veno lymphatic malformation around 4 cms underneath her calcaneous.
She made an appointment with a pediatric orthopedist but was hoping I could give her some answers as to treatment and prognosis. After doing some reading, the treatment of choice seems to be injecting a sclerosing agent, doxycycline to help shrink it. If anyone has treated this type of condition, I would appreciate any input as to the treatment and prognosis.
06/27/2023
QUERIES (CLINICAL)
Query: Pediatric Flatfoot
I see kids but certainly don’t specialize in it. A 7 year old came in with a progressively worsening flat foot. He has a pronounced genu valgum gait and his medial arch, which is flexible, drops all the way to the ground. I suspect an internal hip or knee issue may be contributory. I’m sending him to a pediatric orthopedist for an evaluation further up the kinetic chain. His Achilles does not appear tight as he has plenty of dorsiflexion.
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Pediatric Flatfoot in a 7 Year Old |
I’ve attached an x-ray of his foot and ankle. There is no evidence of medial malleolus ossification and his talus looks extremely malpositioned. His parents and I had a general discussion on shoes and inserts to prevent worsening of the deformity. I was hoping to get thoughts and suggestions from my colleagues who are more experienced with pediatrics.
06/22/2023
QUERIES (CLINICAL)
Query: Source for Peer-Reviewed Prolotherapy References
Could someone please supply those of us who were not trained in the use of prolotherapy with some peer-reviewed references?
Tip Sullivan, DPM, Jackson, MS
06/16/2023
QUERIES (CLINICAL)
Query: Therapeutic Injections of Dextrose
I have been reading numerous articles on therapeutic injections of dextrose therapy, peri-neural injection therapy, and hydrodissection. Most doctors are injecting dextrose anywhere from 12.5 to 25 percent.
1) Does anyone have a source where this dextrose solution can be purchased?
2) If you are doing such injections - would you be kind enough to share your feedback with any pearls or thoughts on the topic?
Jeffrey Kass, DPM, Forest Hills, NY
05/24/2023
QUERIES (CLINICAL)
Query: Recommendation for Nail Laser Therapies for Onychomycosis
I practice in the suburbs of Atlanta. There is a demand here for treatment beyond oral medications. I am looking for advice on nail laser therapies to treat onychomycosis. Any information you can provide is appreciated! Device used, cost, number of treatments, and your own personal experience will be appreciated.
Stephanie Michael, DPM, Cobb County, GA
05/23/2023
QUERIES (CLINICAL)
Query: Recommendation for Anti-Anxiety Medication for Surgical Patients
I have been using 1.5 mg sublingual Ativan pre-surgically for patients undergoing bone procedures. I have noticed many patients are still very anxious. Does anyone use an anti-anxiety medication that has consistently positive results in reducing patient anxiety?
Hartley Miltchin, DPM, Toronto, Canada
05/13/2023
QUERIES (CLINICAL)
Query: Non-Healing Anterior Ankle Ulcer
I have a patient I would like some assistance with. She had angioplasty 3 months ago and the ulcer on the anterior of the ankle has closed by 75%.
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Non-Healing Anterior Ankle Ulcer |
For the last month, I have done laser therapy and local wound care but cannot seem to close her present wound. She refuses to wear a cast, etc. and does not want surgical intervention. Any input would be appreciated.
05/03/2023
QUERIES (CLINICAL)
Query: Unidentified Lesion on Dorsum of Foot
An 88 year old male was seen a week ago with a painful hard raised red nodule on the top of his foot. There was no break in the skin or indication of a foreign body. It looked like possible irritation from the worn out slip-on shoes that were very tight due to his pedal edema or irritated blood vessel. Doppler revealed normal pedal arterial sounds. He is not diabetic, but on BP, cholesterol meds, and ASA 81mg.
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Unidentified Lesion on Dorsum of Foot |
A foam aperture pad was applied over the area and he was fit with a trauma shoe to reduce pressure. He returned today (1 week later) with the area looking like this. There was a large amount of mushy material and this picture is after debridement (without anesthetic). I took a culture, placed him on Bactrim DS for 10 days, and dispensed Telfa pads for qd application. Any ideas on what this might be?
04/11/2023
QUERIES (CLINICAL)
Query: Type of Padding for Diabetic Toe Ulcers?
I have a 74 year old male diabetic patient with recurring toe ulcers at the tip of the left 3rd hammertoe and medially on the left 4th toe. I use a toe crest made of cotton roll to lift the 3rd toe. This helps, but it bunches within few days. The patient needs pad(s) that lift the 3rd toe and separate it from the 4th toe. The patient perspires, but can’t use antiperspirant due to dry skin, and uses powder instead, which usually alleviates the interspace maceration. Any suggestions?
04/10/2023
QUERIES (CLINICAL)
Query: Black Toes from Penicillium
I have a 17 year old patient with black nails 1-10. The culture came back as penicillium. I don’t think a topical would help.
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Black Toes from Penicillium |
Oral ketoconazole or sporanox are mentioned in literature. Both scare me a little. I would like to hear some thoughts.
02/24/2023
QUERIES (CLINICAL)
Query: Flail Toe
This 30 year old female had a previous surgery to correct her bunion and hammertoe. Her pes planus was never addressed. Her chief complaint is a painful 2nd and 3rd toe. I do not have her previous records but it looks like the 3rd toe had a complete intermediate phalangectomy and the second toe had an attempt at PIPJ arthrodesis. The 3rd toe is completely flail past the PIPJ (the main problem) and the second toe is deviated laterally at the PIPJ. I am thinking about using a small piece of autogenous bone to replace the gap left by the absent intermediate phalanx to give some stability and prevent shortening.
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Flail toe |
She does not want a shortened toe. I may be overthinking this and think she might do well with a simple 2.0 axial screw to stabilize the 3rd toe and maintain length. The re-fusion of the second toe in an improved position is fairly straight-forward. I have used small pieces of autogenous bone in past digital reconstructions but seem to get a lot of long-standing swelling. She is self-pay and I’m not interested in using some fancy new expensive implants unless it would be worth it. Suggestions?
02/09/2023
QUERIES (CLINICAL)
Query: Distal Nail Splitting Post Manicure and Pedicure
Today, I had two separate patients complain that their nails started splitting distally on the nail plate after either a manicure or pedicure. The patient reported the condition to be present for some time now. (Greater than one year).
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Distal nail splitting |
In this particular photo, these nails may have concomitant fungus. They are fingers and I’m not treating them. I’m curious though - is this something that can go away?
01/27/2023
QUERIES (CLINICAL)
Query: Post-COVID-19 Muscle Spasms
I am seeing a patient who presents wtih post-COVID-19 muscle spasms in both feet, ankles, and gastrocs. The symptoms are intermittent and many times a day. Heat therapy seems to break the spasm when she gets it. She had one attack while in my office and I applied heat and it stopped the spasm immediately. Has anyone seen this in their practices? if so, how have you managed it?
Name Withheld
01/04/2023
QUERIES (CLINICAL)
Query: Orthotics for Ski Boots
I recently had a couple of patients who are avid skiers. They complained of various foot/ankle ailments. I was wondering if some colleagues who are also avid skiers could chime in on this discussion. I’ve only gone skiing a few times, and I do recall those boots being very snug fitting. I imagine a regular orthotic would not fit in the boot.
Is there a special orthotic “cut” to be recommended that is much narrower that would still fit in a ski boot? Do you have any ski boot "pearls” to share with the rest of us?
Jeffrey Kass, DPM, Forest Hills, NY
