Podiatry Management Online


Podiatry Management Online
Podiatry Management Online



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Query: Night Cramps


I'm at a loss in my treatment of night cramps. I've done the OTC "stuff" with tonic water with some success. The sedatives, antidepressants, and muscle relaxers have had mixed to poor results with lots of side-effects and disqualified patients due to unrelated medications and conditions. I was pretty comfortable with the risk/reward of the quinine sulfate until the FDA eliminated that care plan. I've never been able to match my success/compliance since then. Any suggestions?


M.E. Weaver, DPM, Fort Myers, FL

Other messages in this thread:



Query: Protocol for Testing When Prescribing Oral Antifungals 


I have been doing KOH, cultures, and liver function tests when prescribing oral antifungals for many years. Most of the time, these tests have not revealed much useful information.  As we all know, KOH and cultures are fraught with errors (please do not tell me to use other tests. I work at a community health center and my patients can’t get other tests covered by their insurance). The hepatic function tests rarely indicate serious liver problems. My question is this: has there been any change in standards of care in the testing required to treat onychomycosis prior to initiation of treatment by oral medications?


Edmond F. Mertzenich, DPM. Rockford, IL



Query: AmnioFix for Chronic Plantar Fasciitis 


I recently read several articles regarding AmnioFix injections for treatment of chronic plantar fasciitis. I was wondering how many of my colleagues are using this method. What is your experience and/or results? What is the protocol for this type of treatment? Is special training necessary? What are the risks, complications, and cost?


Paul A. Galluzzo, DPM, Rockford, IL



Query: Transdermal Verapamil for Plantar Fibromatosis


Is anyone using topical verapamil for plantar fibromatosis? If so, where can it be obtained, and how are the results?


Donald Carlson, DPM, Hermiston, OR



Query: Bilateral Heel Pain


My patient is a mailman with rearfoot varus. His pain has been in both heels, especially laterally, until I made orthotics for him. I have detected some diminution of bilateral peroneal muscle strength. His shoe wear of the lateral heel is so severe that a new pair of boots becomes unwearable after a few weeks. At his request, I ordered some OTC heel stabilizers, but these have helped only a little.  


Orthotics of patient with heel pain.


This picture of the worn orthotics really tell the tale: The left lateral heel cup corresponds to his painful left heel. These devices are the fourth iteration of orthotic care for him. Before I remake orthotics with a really high heel cup, I would like the erudite comments on possible treatment options from my esteemed colleagues. 



Query: BOTOX For Pain Management


A patient recently asked me if I use BOTOX for neuropathy pain. I also see a patient who periodically receives BOTOX from a pain clinic for muscle spasms in his legs. In reviewing the literature, I came across several studies in which BOTOX has significantly reduced pain for patients with diabetic neuropathy, trauma, post-surgery, and CRPS for up to 4 months or more.  


I would like to hear from colleagues who have used BOTOX. What is your experience in treating neuropathy and in pain management? Is there any special training necessary? Where do we purchase it and what is the cost?


Tom Silver, DPM, Minneapolis, MN



Query: Nitroglycerin Patches for Overuse injuries


Recently, a patient of mine went to his orthopedist for an Achilles tear and plantar fasciitis. His orthopedist gave him nitroglycerin patches to induce neovascularization. He is improving. Is anyone utilizing Nitro patches for tendon overuse injuries, and if so, what has your experience been? 


Howard Dinowitz, DPM, Brooklyn, NY 



Query: Calcaneal Wound

In the past, I have used drilled bone in the tibia to encourage new tissue growth. I have also used serial bone debridement to encourage tissue growth on the digits and metatarsals. These bone assaults were always on long bones. Has anyone tried any of these methods to encourage tissue healing around the calcaneus? I am considering drilling 3 holes on the medial aspect and 2 more holes through the plantar aspect of the calcaneal bone. The attached picture shows the severity of the soft tissue loss. The green that is covering the soft tissue of the calcaneal bone is from a papain-urea-copper-lidocaine mixture.

Calcaneal Wound

X-rays today show no bone loss from osteomyelitis and no bone is exposed. The patient is on appropriate, culture-result recommended antibiotics, and repeated recent cultures are clean. He has already been treated by a vascular specialist and has severely calcified peripheral arteries. His CBC, except for severe anemia, is WNL. His sed rate is pending. This wound initially killed this patient with sepsis a few weeks ago, but he was resuscitated. I am now seeing him as an outpatient. He is adamant that he does not want an amputation. He has a history of CHF, COPD, IDDM. I vaguely remember that the circulation in the calcaneal bone seems to fade with aging. This patient is about 56 yeras old. If any of you know of an incidence of someone drilling the calcaneal bone for tissue growth, please let me know.



Query: Diabetic Foot Infection  


A 44 year old white male presented with an with ulcer sub 5th MTP with erythema and edema, lateral foot extending to the ankle. MRIs with and without contrast show increased bone marrow signal throughout the 5th metatarsal on T1 and T2. Abscess formation lateral 5th metatarsal is also present.


The patient was taken to surgery for an I&D. A total 5th ray resection was performed. I had hoped to leave some of the 5th met base but decided not to, after finding a large amount of pus around the 5th metatarsal base intra-operatively (and the MRI suggested osteomyelitis of the entire 5th metatarsal). The peroneal brevis was sutured to the cuboid periosteum and the wound was packed open. Bone from the 5th met head was sent for C&S.  Remaining bone was sent to pathology. 


The bone C&S grew out S. aureus and Enterococcus faecalis, both sensitive to vancomycin. Pathology, however, said there was no osteomyelitis in the bone specimen. I feel given the information provided, I treated this infection appropriately; however from a malpractice standpoint, the pathology report suggests otherwise. How does one reconcile the discrepancy? There should be histologic changes if osteomyelitis is present, right?



Query: Neuro-Ophthalmology for Achilles Enthesiopathy


I just received a personal letter from a long-time friend who has been suffering from terrible Achilles enthesiopathy for years. Conservative efforts had failed and surgical intervention had failed to give any resolution. In a last ditch effort, this friend sought help from an ophthalmologist who was extensively  trained in  neuro-opthamology rehabilitation. After two months of wearing special lenses (which are supposed to retrain brain pathways), my friend had complete relief of symptoms. At first, I was very skeptical regarding the theory, but after doing some research my interest has been peaked. Has any podiatrist referred patients for this type of treatment?


Tip Sullivan, DPM, Jackson, MS



Query: Botox for Medial Plantar Neuropathy

A male presented with a two-year history of plantar medial foot pain. He has tried multiple orthotics and therapies with temporary relief only with a local nerve block. MRI reports on two separate occasions are consistent with atrophy of the flexor halluces brevis muscle consistent with a local neuropathy or nerve entrapment. He has well localized pain that is consistent so much that he only wears Crocs as this gives him the ability to be ambulatory without severe pain. While this is looking like a surgical case with release of the medial plantar nerve, does anyone have any experience with Botox injections in the foot as this is being requested by the patient?



Query: Painful Mass on Forefoot


This is a 57 year old female with a painful, stable mass of the left forefoot, present for 4 years since moderate trauma to the area. She describes it as an extra bone. There is a history of a parathyroid mass with elevated parathormone and calcium levels present at the time, but it is controlled now after surgery. Her neurovascular status is intact. The mass is palpable just lateral to the plantar 2nd metatarsal head. 


X-Ray of Painful Mass


On x-ray it resembles myositis ossificans and may very well be owing to the stability of the mass. I think a malignant process would have manifested itself after 4 years, especially since there is no osseous destruction. This can be easily treated with an accommodative orthotics. My question for the group is whether a further diagnostic work-up is warranted. CT, MRI, or biopsy? We would like to keep invasive care to a minimum if possible. Any thoughts?




Query: Peroneal Longus Tendon Rupture


I was recently referred a 50 year old fairly active male with two weeks status-post a  90 percent peroneal longus tendon rupture at its insertion. Besides the long-term ramifications on the first metatarsal and architecture of his foot, is surgery an option for this patient? 



Query: Dystrophic Nails in 18 month Old Boy


Below are photos of thick toenails growing in a dorsal direction. A trial of topical urea was attempted, but the parent stated that this made the nails "gummy" and wants other options. 


Dystrophic Nails in 18 month Old Boy


I know how I would handle this in an adult, but I am looking for advice for this 18 month old boy. 



Query: Pitting and Discolored Hallux Nails

I saw this healthy, active 33 year old female in May regarding bilateral hallux nail discoloration. She is not taking any medications. She believed she damaged the nails with a pair of new shoes. I told her to allow the nails to grow and then return for re-evaluation. During the summer, her family doctor prescribed cortisone cream, psoriasis medication, and did 3 fungal cultures, all negative.

Pitting and Discolored Hallux Nails

I recently examined her nails and they look the same as previously, without growth distally. There is an area laterally, midline, that is discolored and pitted. X-rays were negative for a subungual exostosis. What I find unusual is that the pitting occurred at the same time and that the areas are in exactly the same location bilaterally. Any suggestions?



Query: Surgery or No Surgery?


I have a patient scheduled for bunion surgery in about 2.5 weeks. I repaired her contralateral foot last year. She called me today and told me that she just had a cardiac stent placed 3 days ago. She discussed this planned surgery with her cardiologist, who basically told her that the surgery would be fine with him and that the only issue should be that he did not want her off her anticoagulant. Typically, he will leave patients on an anticoagulant for a year and then re-evaluate. She does not want to put off her surgery for financial reasons. This patient understands the risks and has asked me to proceed with her bunionectomy. Surgery or no surgery?



Query: Non-Healing Biopsy Site


I'm a 70 year old podiatrist in good health. Six weeks ago, during a regular skin exam, a suspicious lesion was noted on the plantar lateral border of my left foot. A shave biopsy revealed an acral compound nevis with some irregular cells. I was informed a future excision may be needed. The biopsy site has not healed after six weeks.


Non-Healing Biopsy Site


Treatment has included daily cleansing, dressed with Aquaphor, sterile padding and cushions to reduce shoe pressure. 10 day course of a cephalosporin, then 10 days of doxycycline did not reduce the surrounding erythema.  Any suggestions would be appreciated.



Query: Post Hyfrecation of Verruca on Hallux


I performed a hyfrecation/electrocautery debridement with a total nail avulsion of a great toe. This surgery was performed to remove an aggressive mosaic verruca. After attempting to remove this lesion via currettage a month ago, it returned with a vengeance. The procedure was performed on a fairly healthy female in her forties. It has been two weeks since the procedure was performed. Now, I have concerns over the tissue loss caused by the electric debridement. I understand that the procedure has caused a burn with resultant tissue necrosis, and hence, my goal is getting the toe to heal via second intention.


The patient is partial weight-bearing in a post-op shoe. I have been using Adaptic and Amerigel to dress the toe. There is an expected moderate serous drainage from the wound related to this procedure. There is skin slough and a granulation base. The patient is taking oral antibiotics. I am concerned that if does not heal through second intention, then a digital Symes amputation of the distal phalanx may ensue. Comments please.



Query: Unusual Nail


Unusual Nail


This is a 62-year-old patient who has a history of erythromyelgia. He has had a deformity on his toenail for about 18 months. He cannot recall any trauma. All of his other nails are normal except this one. Does anyone have any idea what this could be?



Query: Painful Hallux Status-Post I&D

I saw an otherwise healthy 61 year old patient who had an I&D of a paronychia. She wound up needing round after round of antibiotics despite her initial C&S coming back "normal skin flora." She has been seen by an ID specialist and her labs have always been normal.  

Her MRI shows signal changes in the distal and proximal phalanges "suggestive" for osteomyelitis. I have since taken bone biopsies including bacteria, fungal, and AFB, all of which were normal, yet she still has pain in the toe. The toe itself clinically looks fine, but she is still in pain. Any suggestions?



Query: Hallux Trauma


A 47 year old healthy female consulted with me approximately 6 months after dropping a heavy object from her freezer on her hallux. She saw her family doctor as well as 2 dermatologists due to pain, erythema, and edema not resolving. She tried a number of prescriptions, topical cortisones and a course of erythromycin. When I examined the hallux, there was nail growth midway and purulent drainage from beneath the eponychium. Radiographs were negative for fracture or subungual exostosis.  


(L-R) Pre- and Post-Avulsion Hallux


I placed her on Cipro 500 mg bid, soaks bid, and topical antibiotic dressings. After 2 weeks, there was no change and some clear drainage continued. I removed the hallux nail and there was some clear drainage for approximately 2 weeks. I continued the previous treatment regime of oral/topical antibiotics and soaks. The pain subsided within 2 weeks. Currently, there is no new nail growth evident and there is no pain or drainage. The hallux continues to exhibit significant erythema and very firm edema surrounding the entire distal half of the digit, especially at the tip. I have tried multiple laser treatments utilizing various lasers, without success. Any suggestions on further treatment?



Query: Complication From Excessive Surgery

A 56-year-old healthy female underwent multiple foot procedures on July 20, 2016. She presented to the wound clinic on August 19 with abscess/ascending cellulitis and gangrene to the distal 2nd & 3rd toe with dehised incision lines at all surgical sites and grew MRSA. 95% of her incisions have healed. The only incision not healed at this time is the distal medial aspect of the hallux IPJ; I believe we will close that as well.

Complication From Excessive Surgery

Her complaint is digital pain at the hallux IPJ. As you can see from the x-ray, there is bone on bone contact. At this point, I am looking for some advice on long-term treatment. Presently, I have her in a hard-soled shoe to limit motion at the IPJ. Going forward, this IPJ will probably need revision. Would you consider revisional arthroplasty, digital implant, or fusion of the IPJ?This case is an unfortunate, horrific event for this young active vibrant individual, and is a lesson for all of us that too much surgery in one sitting may not be in the best interest of the patient.



Query: Isolated Edema and Skin Changes of the Left Foot


I had a patient come in with an unusual complaint. I wonder if anybody out there can give me some ideas what I might be dealing with. The patient had a history of a midfoot stress fracture that was diagnosed by another doctor in April. She states that it became very swollen and the swelling never went away. She denies any pain at this time but states that no matter what she has tried, the swelling will not resolve. She has had some lightly compressive hosiery. She has tried massaging the area. She has rested and elevated the area without relief.


Isolated Edema and Skin Changes of the Left Foot

Evaluation of the patient's left foot shows significant difference from the right. Some violaceous changes of the left foot skin is noted compared to the right. The toes are swollen and the skin on the top of the toes is hardened. Palpation of the edema reveals no pitting. The consistency under the skin appears to be more like fat.



Query: Gout and Charcot Foot?


I am treating a patient with acute and chronic gouty arthritis. Recently, he presented with pain in the left rearfoot which was not responsive to injections or oral meds. An MRI came back with findings of multiple fractures suggestive of Charcot foot. He has no signs of neuropathy or diabetes. I sent him for neurological testing to see if there were any signs of neuropathy. There were none. Has anyone seen a case like this?



Query: Bony Changes

The patient is a 66 year old real-life cowgirl who, four years ago, without history of trauma, and no abnormal family history, began experiencing “deep aching pain” in her dorsal left midfoot. She is otherwise healthy, taking no drugs, and still working full-time. I was surprised by the x-rays showing some degenerative findings.

Bony Changes

I am making orthotics for her to help stabilize her foot/feet in gait; tight boots—that diminish midfoot motion—reduce some of the pain; hence the reason why, at first blush, orthotics appear to be the first, and most conservative treatment. I now wonder if this may represent a bone tumor or other degenerative disease and request any advice on how I should proceed. 



Query: Surgical Recommendations


These foot x-rays are of a 45 year old healthy female. I would like to hear any surgical suggestions. Her chief complaints for which she would like surgical correction are the following: 1) Bilateral symptomatic tailor's bunion pain and 2) Congenital overlapping 5th toes, which are not painful, but she would like cosmetically corrected so that they sit flat and straight when walking, standing, and when she is wearing open or closed toes shoes.


A-P and Lateral X-Rays


What is the best way to adequately correct her tailor's bunions (which usually further shortens the 5th metatarsal). Note she has some atrophy of the plantar forefoot fat pad with painful thickening and callus under the 5th metatarsal heads (plantarly). She also has diffuse non-painful tylomas under the 3rd and 4th met heads bilaterally due to a compensated equinus condition, and a short and splayed 5th  metatarsal length pattern.