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: Treatment of Plantar Scar


I excized a soft tissue mass from the plantar aspect of a patient's foot. She healed uneventfully; however, a plantar scar presented with a punctate keratotic lesion (similar to porokeratosis). I tried salicylic acid as well as silastic gel sheeting, both of which were ineffective at resolving the lesion. I took her back to surgery and performed a Schrudde skin flap. Unfortunately, that scarred up too and now she has another lesion that is bigger than the first one. Does anyone have any other non-surgical suggestions? 



Query: Calcific Tendonitis


A 38 year old male tennis coach and runner presented with 5+ years duration of left TAL and arch pain. He has tried multiple OTC insoles, night splints, KT taping, stretching, Advil, icing, and is essentially getting no better. This is starting to limit his activities. An exam showed moderate ankle equinus (straight knee), moderate medial plantar fascial band pain (heel pain is spared), and hallux limitus, but an x-ray is clean in terms of any spurring.  


Calcific Tendonitis


There is TAL pain at the lower edge of the calcification. Haglund's deformity has also been noted. I strapped his foot with a moderate low-Dye and also added 1/4" felt to his heel.  He had no relief at all after 48 hours. I am looking for possible custom orthotic recommendations before recommending surgical intervention. Suggestions?



Query: Tibial Sesamoiditis in Dancer


I have a question concerning a 16 year old female who likes dancing, and wants to pursue it as a career. She has a forefoot valgus of 5 degrees left foot with a prominent head of the 1st metatarsal. ROM of the ankle, STJ, and 1st MTP were normal. The pain is located on the tibial sesamoid. X-rays were normal. The right foot was normal.


She likes to dance both with shoes and barefooted. She is not interested in ballet. The patient has had this discomfort for three months, and reports it has gradually increased in intensity. The question I have is what would be the best form of shoe and/or orthotic treatment? Are there other treatments I need to look into?  



RE: Metallic Foreign Body Within a Toenail Plate


While mechanically debriding a hypertrophic hallux nail plate, I noticed I was not making progress reducing the nail and also heard an odd noise from the grinding disc. Close inspection of the nail plate revealed a localized dark discoloration that appeared possible for metal. Clinically, there was no sign of infection, erythema, exudate, or any other soft tissue manifestation. AP and hallux lateral elevated radiographs confirmed an apparent metallic foreign body within the nail plate proper. There was no nail bed penetration and likewise no osseous breach at the dorsum of the distal phalanx. No other foreign body fragments were evident.


Metallic Foreign Body Within a Toenail Plate


There was no contributory history to explain the foreign body presence. The patient denied history of failed or problem self-care. The patient has dystrophic onychomycosis in multiple nails. There is no history of neuropathy, vascular disorder, or diabetes. There is no major ambulatory defect. Does anyone have any explanation for the etiology of this?



Query: Syndactyly in an 11 Month Old


An 11 month old presented with bilateral syndactyly of the first and second toes. There are no other digits involved, and the patient does not have a family history of syndactyly. The patient does not yet independently ambulate and does not “want to walk” according to his mother. The pediatric orthopedist  gave the child a clean bill of health except for the syndactylized toes (no osseous abnormality) and some strabismus which may be causing some visual difficulties.


Syndactyly in an 11 Month Old


His mother believes that because his nail on the second toe seems to irritate the first, he does not want to walk. Basically, I taught the mother how to conservatively manage his nail until he is older and is able to ambulate. The syndactyly is mostly a cosmetic problem at this point. If the nail continues to be an unmanageable problem and requires surgery which will require anesthesia, then I plan to repair the nail and do a desyndactylization at the same time. Comments welcome.



Query: Bulbous Lesion on Distal Hallux


This is a 26 year old male with a growth tip of right great toe present for "a few years". It is getting larger. There is no history of pain or trauma. PMH: unremarkable. There is a bulbous firm lesion tip of hallux extending under the distal nail plate. X-rays reveal no osseus pathology.


Bulbous Lesion on Distal Hallux


A biopsy is scheduled before determining future treatment. If the lesion is benign, what is the best way to remove this lesion in order to close the likely large soft tissue defect?



From: John D Lanthier, DPM


Dr. Graziano: Can you please describe the flap that you used in this interesting case of tophaceous gout?


John D Lanthier, DPM, Sudbury, ON



Query: Curled Nails in 8 Year Old Boy


This is a healthy 8 year old boy. Developmentally, he was a little delayed with walking - 14 months. He seems to be a fairly habitual toe-walker. His parents try to encourage correct walking, purchase shoes with stiffer soles, yet it still persists. There is certainly a considerable amount of forefoot ambulation with virtually no heel-toe. Periodically, there is slight in-toe left. He does not trip or fall. He has a deviated-curled varus 2nd toe at the DIPJ bilaterally.  


Curled Nails in 8 Year Old Boy


The main concern is the ends of his toes and nails. He is doing Karate, with pain to the distal toes and nails. Cutting his nails has always been a chore for mom. Sometimes, bleeding occurs. The nail beds appear to be rounded with a slight dorsal bump with the nail curling over. The DIPJ is in rectus, with no 'fixed' or rigid contracture. Any advice would be appreciated.



Query: Surgery to Remove Gouty Tophi


I currently have a patient whom I treated for the second gouty attack in his right big toe joint. The first attack was 18 months prior. Grossly, it looks like he has huge bunion bumps bilaterally, but they're all tophi. Now that the pain from his recent gouty attack is resolved and his uric acid is down to normal levels, I plan to surgically remove the gouty tophi from his big toe joints (with the right foot initially and the left foot once the right is healed).  


X-Rays of Gouty Tophi


I have surgically removed tophi from around toe joints periodically in the past, but this patient has larger deposits around the joint than I have ever removed before, and it appears to extend all the way around the joint and into the first interspace. I would like to hear from my esteemed colleagues regarding any pearls they might have regarding removal of such a large number of tophi from around the big toe joint.



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.