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08/27/2015
RESPONSES/COMMENTS (CLINICAL) - PART 2
RE: Are We Still "Kings" of Orthotics? (Doug Richie, DPM)
From: Elliot Udell, DPM
True, the paper by Wrobel, et al., did not show that custom orthotics were the be all and end all in the management of all symptoms caused by plantar fasciitis. Yes, it showed a 125% improvement in spontaneous activity over three months as compared to pre-fabricated orthoses. It did not show improvement in pain. This is why all of us use injections, physical medicine, NSAIDs, etc., in addition to custom orthotics in the management of plantar fasciitis.
What is most significant with Wrobel's paper, however, is that it is a good attempt at bringing evidence-based medicine to one aspect of biomechanics and foot orthoses. Up until now, education in biomechanics has been, by and large, in the domain of self-declared experts. They occupy bully pulpits at conventions where they espouse their own theories of how an orthotic should be made and why it works.The obvious problem is that if you attend five lectures by five different individuals on this topic, you will hear five different sets of conflicting theories and recommendations. This is because the information given by these speakers has not stood up to the scrutiny of solid university-based research. We need more papers like that of Wrobel, et al. Then biomechanics and custom orthoses will graduate from pet theories into actual science.
Elliot Udell, Hicksville, NY
Other messages in this thread:
03/13/2024
RESPONSES/COMMENTS (CLINICAL) - PART 2B
From: Robert Kornfeld, DPM
I have spent more than 30 years treating chronic foot and ankle pain and have had many cases of “recalcitrant” PT tendinitis. Once you come out of the “next best treatment” mentality and focus on the patient, you will find answers. Functional medicine teaches you to examine the patient's total health landscape to uncover immune burdens and any epigenetic and genetic issues (SNPs) which will create inefficiency in repair pathways. These underlying mechanisms are managed prior to any treatment. Once you have up-leveled immune function, you can heal these chronic cases via regenerative medicine injection therapies. This is how every doctor should be practicing. I have loved my practice all these years.
Robert Kornfeld, DPM, NY, NY
03/13/2024
RESPONSES/COMMENTS (CLINICAL) - PART 2A
From: Jeff Root
Regarding the query about the treatment of recalcitrant "posterior tibial tendonitis", or what many would call posterior tibial tendon dysfunction (PTTD), I would like to share a few of my thoughts. The PM News subscriber stated that the patient wears "HOKA shoes and custom orthotics". The term "custom orthotics" simply implies that the devices were not prefabricated. In some cases, the lines between custom and prefabricated shoe inserts have been intentionally and unintentionally blurred. In addition, the term "custom orthotics" tells us little to nothing about the nature (i.e. design and properties) of the orthoses because there are hundreds if not thousands of types of custom orthotics and orthotic designs.
For example, what was the position of the joints of the foot, including the STJ, MTJ and 1st ray when the foot was casted or scanned? What were the specifications of the orthotic prescription? What lab techniques were used in creating...
Editor's note: Jeff Root's extended-length letter can be read here.
06/30/2023
RESPONSES/COMMENTS (CLINICAL) - PART 2
From: H. David Gottlieb, DPM
Yes, Dr. Sullivan, prolotherapy has been around and used by podiatrists for a long time. My uncle started his podiatry practice in 1934 and my father joined him in 1943. They used prolotherapy using sodium moruate and/or alcohol, I believe. They were no longer using it when I joined them in 1982 but it was presented to me in a positive light. It seemed to me at the time that uncle was more focused on palliative care and orthotics and my Dad on office-based 'open' surgery.
I never learned the technique but believe that it has a place in ligamentous and other soft tissue conditions.
H. David Gottlieb, DPM, Baltimore, MD
06/28/2023
RESPONSES/COMMENTS (CLINICAL) - PART 2
From: Steven Belanger, DPM
Not everyone has the ability to have a concierge practice or a holistic practice that does not participate in any insurance plans. The reason for this is very simple. If someone practices in a relatively low income area, a doctor would go broke offering this type of service, as no one has the ability to pay for these services no matter how great or wonderful they are. So not everyone can just do this.
Steven Belanger, DPM, Fall River, MA
03/31/2022
RESPONSES/COMMENTS (CLINICAL) - PART 2
From: Steven Finer, DPM
When I was in practice, I used the standard toe block as previously described. After the wait time if the toe was still sensitive, I would have the patient hang their foot over the side of the chair for five minutes. I would re-enter the room and 95% of the time, the toe was numb. Maybe it was the additional time or gravity playing a part. For the other 5%, I re-injected and used ethyl chloride anesthesia spray.
Steven Finer, DPM, Philadelphia, PA
03/30/2022
RESPONSES/COMMENTS (CLINICAL) - PART 2
From: Ivar E. Roth, DPM, MPH
I would like to recommend two options when local anesthesia fails due to an infection. First, I think we should never cause intentional pain to our patients. All you need to do if a toe block fails is do a PT block and a deep peroneal block. Second, I use nitrous oxide with anxious patients or those that have a low pain threshold; it knocks down the anxiety and pain by at least 80%.
Ivar E. Roth, DPM, MPH, Newport Beach, CA
03/29/2022
RESPONSES/COMMENTS (CLINICAL) - PART 2
From: John Lanthier, BSc, DPM
I have read with interest the previous posts with bewilderment as I have never had a problem or concern achieving total anesthesia on a digit. However, this week, a patient came into the office with a chronically infected hallux that was insufficiently treated with multiple rounds of antibiotics and painful failed surgical intervention from the emergency department. We all get these, and you smile, knowing that this will be a chip shot and you will be the hero.
After two rounds of standard local anesthetic of 8cc total in a standard H block with Lidocaine and Marcaine and 20 minutes to allow it to work, the blocks failed both times; even after a repeat block. I felt that no more could be given as it was risking vascular compromise due to too much volume in a confined anatomical location. I did what had to be done and removed the retained nail pieces left in the borders from the previous failed attempts. The patient was in pain, and I felt terrible, but I had to do what I had to do to get the job done. Never say never.
John Lanthier, BSc, DPM, Sudbury, Ontario
03/16/2021
RESPONSES/COMMENTS (CLINICAL) - PART 2
From: Howard Dananberg, DPM
We tend to view hallux limitus and turf toe as being painful because it moves. I instead suggest that the joint hurts because it DOESN'T move when the motion demand is the greatest. It is also important to keep in mind that once the hallux makes ground contact, it is completely stationary until toe-off. Restriction to motion is in the metatarsal component of the joint, not the toe.
The use of carbon fiber plates and other stiffening devices can never resolve the symptoms in the long term. This will only serve to increase stiffness and perpetuate the underlying mechanics of the problem. They may be temporarily helpful for short-term relief of a true joint sprain, but otherwise...
Editor's note: Dr. Dannanberg's extended-length letter can be read here.
01/08/2021
RESPONSES/COMMENTS (CLINICAL) - PART 2
From: Annette Joyce, DPM
The best way to understand the types of rashes that appeared in the Internet post Eat This, Not That would be to read and review the original JAMA articles below, available without a subscription due to COVID content.
The original JAMA article on the petechial flexural eruption has pictures.
Annette Joyce, DPM, Sykesville, MD
12/07/2020
RESPONSES/COMMENTS (CLINICAL) - PART 2
From: Barry Mullen, DPM
Seth Orlow (J Am Derm 28:794, 1993) first reported his successful experiences treating warts in 36 children with cimetidine. In an effort to enlighten our profession, I re-reported my 5 year anecdotal experience in a larger sample size of pediatric patients (JAPMA 95(3):229-34, 2005). Griswold (J Immunology 132:3054, 1984) demonstrated Cimetidine’s immuno-modulatory effect in mice via T suppressor cell suppression. That’s the EBM behind cimetidine’s mechanism of action.
15 years later, I’m happy to report cimetidine continues to work about 85 percent of the time in children under 18. This is a wonderful, non-invasive therapy that is perfect against multiple mosaic verrucae affecting large surface areas of the foot. It keeps your pediatric athletes on the playing field during sports season(s). I have, and do use it for adults with less frequency and reduced success rates, especially those over 200 pounds (FDA max allowance is 1,600 mg/day while therapeutic doses range from 20-25 mg/kg in divided doses). Since it has the ability to enhance T helper cell ratios, it stands to reason there’s a chance it could temporarily boost the immune system in someone who’s compromised.
In these difficult cases, I’d strongly recommend conferring with the physician who’s treating the illness creating the immunocompromised state and ensure it assimilates with other concurrent meds.
Barry Mullen, DPM, Hackettstown, NJ
12/04/2020
RESPONSES/COMMENTS (CLINICAL) - PART 2
From: Tim Shea, DPM
This topic is spot on regarding the concomitant use of immune suppressive medication and the difficulty in treating plantar warts. Currently, there are many different specialties (such as dermatology, rheumatology, oncology, etc.) where a patient is placed on medications which have an immune suppression effect. Many of these patients are unaware that the medication they are taking has this side-effect, other than the clinical effect they are looking for. Some don't even report them as a medication they are taking.
Commonly, these lesions present as the mosaic variety and are very resistant to most topical therapies. Tracy Vlahovic DPM, has an excellent article and talk she presents on the treatment of verrucae as a whole. It points out the benefits and failures of many topical therapies that we commonly use. Most topical therapies rely on stimulating an inflammatory response to the medication and "killing" the virus in the skin. If someone is on these medications, then there will not be an adequate response, and it may actually cause a local response (Koebner effect) in the skin that leads to scarring. These are very frustrating lesions to treat and have high rates of recurrence.
I have no personal experience, but I am hopeful technologies, such as microwave (Swift by Saorse, and others), will offer a more logical and effective way of combatting these conditions, when the internal immune system is modified. Disclosure: I have no fiduciary relationship with Saorse.
Tim Shea, DPM, Concord, CA
09/10/2020
RESPONSES/COMMENTS (CLINICAL) - PART 2A
From: Stephen Musser, DPM, Richard M. Maleski, DPM RPh
An additional x-ray view would be helpful. Addressing the contracture at the MTP is critical either with a Weil and/or soft tissue release. Equally important is the the use of a toe splint(s), Darko, used afterwards to keep the digits in a corrected alignment for the soft tissue to heal/scar down the toe in the desired position, with proper alignment until scar tissue and adhesions are formed.
Stephen Musser, DPM, Cleveland, OH
I agree that transverse plane deformity of the lesser digits is very hard to correct and have always tried to avoid surgery for these. In one case that was successful, in addition to PIPJ fusions of the 2nd and 3rd toes with pin fixation across the MTPJs, I performed capsulotomies and capsulorraphies of the MTPJs as well as base wedge osteotomies of the 2nd and 3rd metatarsals to correct for the small amount of met-adductus that was present. I also freed up the extensor tendons from the insertion to about the metatarsal neck area, and sutured the tendon sheath apparatus in a more medial alignment, to try to relieve the lateral pull of the tendon across the MTPJ.
I followed the patient, who was very active, for 4 years until I retired. At least until then, the correction held up very well and the patient was happy. I can only hope that the correction will continue to last. This is the only time I performed this combination of procedures and I think that the correction of the met-adductus, although seemingly minimal, was key.
Richard M. Maleski, DPM, RPh, Pittsburgh, PA
07/21/2020
RESPONSES/COMMENTS (CLINICAL) - PART 2
From: Michael J. Schneider, DPM
Regarding Dr. Markinson’s comment on the Panacos graft to treat intractable verrucae, we performed this procedure many times in our practice with excellent outcomes.
Michael J. Schneider, DPM, Denver, CO
07/20/2020
RESPONSES/COMMENTS (CLINICAL) - PART 2
From: Todd Lamster, DPM, Estelle Albright, DPM
I congratulate the doctor who has helped heal this chronic wound. I would like to know: Was a biopsy first performed to rule out carcinoma? I postulate that the debridement with Unna boot compression and antibiotics probably had more to do with healing rather than the Bactroban and Medihoney, even though those are good choices for topicals once you kick-started the process.
Todd Lamster, DPM, Scottsdale, AZ
I have successfully used Medihoney gel and Bacitracin ointment in a 1:1 mix successfully as well on wounds. It works well if the wound is painful, and/or you do not want dressings to stick to the wound.
Estelle Albright, DPM, Indianapolis, IN
07/17/2020
RESPONSES/COMMENTS (CLINICAL) - PART 2
From: Pedro nel Sanchez
I recommend having your patient wear a high top athletic shoe with a carbon microfiber AFO. An over-correction strap around the tibia and fibula gives a lot more stability and ankle support. This device is very lightweight and extremely flexible so it provides for easy ambulation.
Pedro nel Sanchez, pedorthist, Flushing, NY
01/14/2020
RESPONSES/COMMENTS (CLINICAL) - PART 2
From: Michael Kaminsky, DPM
Consider contacting your local Synthes rep. They have a full hardware removal tray. It should include a wide variety of screw driver heads and reverse drill bits that you can use to back out the screws.
Michael Kaminsky, DPM, Plainfield, NJ
Last year, I was presented with a patient who had hardware that was placed in her foot a year previous that needed to come out. Wright Medical was very helpful and provided me with their kit that had drivers for every type of screw head configuration and I was able to remove the two particular hex screws that were previously placed.
Also, a company called Shukla Medical has an extractor that can remove any broken or stripped screws.
Robert Chelin, DPM, Toronto, Canada
12/05/2019
RESPONSES/COMMENTS (CLINICAL) - PART 2
From: Kim G. Gauntt, DPM
I acquired my first ultrasound some 20 plus years ago. I learned in workshops to do the guided injections. The guided plantar fascia injection is my primary use therapeutically; the ultrasound is a very versatile imaging modality diagnostically.
The only way to measure the “effectiveness” is from what patients tell you who have had both. Since I don’t inject the fascia without it, my feedback is from those who have come from other practices over the years where non-guided injections had been given and the overwhelming majority say...
Editor's note: Dr. Gauntt's extended-length letter can be read here.
10/21/2019
RESPONSES/COMMENTS (CLINICAL) - PART 2
From: Don Peacock DPM, MS
The surgeon did a great job with this. The minimally invasive Austin Akin for bunion correction is not a new technique. The first article on the subject was published by Gorman and Plon in 1983. They used non-fixated osteotomies. The Wright procedure known as the MICA (minimally invasive Chevron Akin) is the same procedure many U.S. MIS podiatrists have employed for over 40 years. The only thing new is the use of headless compression screw fixation instead of K-wires, regular screws, or non-fixation. The combination of MIS and compressive screw fixation does yield great results as reported in the literature. The debate between fixated and non-fixated MIS techniques has not been put to the test by comparative research.
The x-ray appears to have a nice correction. The pre-op angle is >18 and the post-op angle IM is around 2. This is...
Editor's note: Dr. Peacock's extended-length letter can be read here.
02/26/2019
RESPONSES/COMMENTS (CLINICAL) - PART 2
From: Burton J. Katzen, DPM
Those of us who perform non-fixated distal percutaneous metatarsal osteotomies can attest to excellent results that are obtained when performed by a well-trained MIS surgeon. One technique to prevent lateral or medial deviation is that instead of simply performing the osteotomy straight across, drilling a fail-safe hole and performing a "V" osteotomy. This technique allows for better stability and less soft tissue interaction since you are only cutting within bone. There also are several other factors that might be considered:
1. The angle of the cut which can be proportional to the amount of correction desired.
2. The relative metatarsal length pattern.
3. The Leventen formula to decide whether multiple metatarsals need correction.
4. The relative plantar protrusion of the adjacent metatarsals, which can be tested by dorsiflexing the toes and palpating the metatarsal heads (Peacock press).
5. The amount of equinus, especially with diffuse metatarsal calluses or pain.
I have been performing percutaneous non-fixated metatarsal surgery since 1980 and have never had a non-union, even in elderly patients where traditional surgery with fixation would be much more risky. It is our hope that these and other MIS procedures will soon become part of the academic curriculum in the schools and podiatric surgical residencies.
Burton J. Katzen, DPM, President, The Academy of Minimally Invasive Foot and Ankle Surgery
Editor's note: This topic is now closed.
02/08/2019
RESPONSES/COMMENTS (CLINICAL) - PART 2B
From: Allen Jacobs. DPM
The observation of Dr. Jones that activated folic acid may be helpful for the management of Reynaud's disease or phenomenon is not without a potential, although unproven, scientific basis. The utilization of l-methylfolate, B6, and methylcobalamin, increases nitric oxide levels. Nitric oxide is of course a well-established powerful vasodilator. It is also helpful in the reduction of homocysteine which is a non-essential amino acid inhibiting the coupling of nitrogen and oxygen to produce nitric oxide. It is now available in a generic form through EBM Phramacy.
Allen Jacobs. DPM, St. Louis, MO
02/08/2019
RESPONSES/COMMENTS (CLINICAL) - PART 2A
From: Elliot Udell, DPM
Drs. Albritton and Jones show that there are multiple ways to skin a cat. In this case, the cat is the treatment of Raynaud's phenomenon. As Dr. Jones indicated, some people are hesitant to take an oral medication that is off-label for Raynaud's but FDA-approved for the management of hypertension. In our practice, we have done well with recommending disposable shoe warmers that are sold in sporting goods stores. Patients buy a box of them in December and it lasts until the spring. For others, we have successfully prescribed long-acting nifedipine. These patients take one pill a day starting in December and discontinue the drug when spring arrives. We check blood pressures on these patients before starting the drug to make sure they do not have hypotension and when they start, they are advised not to get up from a sitting position too quickly.
Two important points to consider are: 1) If the patient is taking other medications for hypertension, adding on nifedipine or the meds recommended by Dr. Albritton could cause an abnormal drop in the patient’s blood pressure. In those cases, it is wise to coordinate treatment with the patient's primary care physician. 2) Order an ANA on patients presenting with symptoms for the first time to rule out the possibility of scleroderma or lupus.
Elliot Udell, DPM, Hicksville, NY
12/29/2018
RESPONSES/COMMENTS (CLINICAL) - PART 2
RE: PRP Injection for Plantar Plate Tear
From: Allen Jacobs, DPM
Without knowing any further details, PRP injection possibly mixed with additional stem cell augmentation (e.g.- amniotic derivatives) would be the procedure of choice. Your patient should understand the future potential risk of rupture.
Allen Jacobs, DPM, St. Louis, MO
07/31/2018
RESPONSES/COMMENTS (CLINICAL) - PART 2
From: Donald J. Adamov, DPM
In my 13 years of clinical practice, I estimate that 2-3 people out of every 100 experience the metallic taste in the mouth with oral terbinafine. Most of these patients were able to deal with it. I do recall one patient several years ago to whom it became very bothersome. It took a couple of weeks to resolve after stopping the medication.
At the time, I did a Google search on this and found a case of a gentleman, in I believe the UK, who was actually hospitalized because he didn't want to eat due to the taste disturbance. In my experience, the taste disturbance with oral terbinafine is rare and to become a big problem is incredibly rare.
Donald J. Adamov, DPM, Spring Hill, FL
07/30/2018
RESPONSES/COMMENTS (CLINICAL) - PART 2
From: Allen Jacobs, DPM, Neil Barney, DPM
I must admit to “shock and awe" at the recent discussion regarding loss of taste with oral terbinafine. Loss of taste is one on the most common adverse sequels of this medication, occurring in greater than 1/50 patients. Although typically reversed with discontinuation of terbinafine, loss of taste may be permanent. I suggest that in the future, practitioners might familiarize themselves with the FDA package insert before prescribing medications, or offering commentary regarding potential medication side-effects.
Allen Jacobs, DPM, St. Louis, MO
After over writing 200 scripts for terbinafine, I have seen 3 cases of taste disorder that caused the patient to stop its use. Taste came back within days of stopping. No ill effects were noted thereafter. As an aside, not one case of elevated liver functions was found in those patients tested.
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Neil Barney, DPM, Brewster, MA
06/25/2018
RESPONSES/COMMENTS (CLINICAL) - PART 2
From: Bryan C. Markinson, DPM
In the case presented on dermal sarcoma, it would have been better to first do a biopsy on a portion of the lesion. As presented, primary excision before knowing the biology of the lesion is not optimal. Histologic findings not only identify that the neoplasm is malignant, but a biopsy can give important information as to the aggressiveness of the tumor. As such, it is better left in the patient until that info is known. When excised primarily, only to find out it was malignant afterwards, this presents problems for wide excision planning. What may have been a conservative but complete excision now has to be expanded to a much wider surgical field as the tumor margins are now not reliably identifiable. On feet, this may create the need for an otherwise unnecessary amputation or need for free flap.
Additionally, patients need to be staged before complete excision. Definitive local surgery planning will often change if the patient has been found to have metastases. Lastly, some tumors require local radiation and/or chemo before definitive surgery is performed. The best way to go in a case like this is an initial biopsy. If benign, planning for excision is easy and straightforward. If malignant, referral to a university/hospital-based sarcoma treatment team with tumor intact is optimal.
Bryan C. Markinson, DPM, NY, NY
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