Podiatry Management Online


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Query: Relentless Heel Pain


We had a healthy 23 year old male present for fat grafting to his heel. He was a competitive ski jumper. Two years prior to his visit to us, he jumped and landed wrong on his left heel. He developed severe left heel pain but reported that his x-rays and MRI studies did not reveal a fracture. Initially, he limited weight-bearing and pressure on his left heel without relief. He reported he tried orthotics, had PT, EPAT, and “stem cell treatment with placenta”, but continued to have pain after two years of these various treatments. He presented to us asking for autologous fat grafting.  


On examination, he had minimal pain on direct palpation of his heel but no pain on compression of his heel. He had a palpable “click” at the plantar central aspect of his heel. X-ray, ultrasound, and MRI were all negative for pathology. He reported that pain is always present when standing and walking on his heel, but it was difficult to elicit pain on palpation. We did attempt autologous fat grafting in the hopes the adipose tissue could ease any scar tissue he had. He is 9 months post-procedure with only minimal relief. Does anyone have any thoughts or ideas about his heel pain?

Other messages in this thread:



Query: Treatment of Interdigital Maceration


I have a few patients with excessively macerated skin between their toes - usually seen in the 3rd and 4th interspaces. There is typically no evidence of tinea infection. This appears to be caused by medial contraction of toes, which in turn causes very tight interspaces to become chronically moist. 


I have tried toe spacers, lamb's wool, etc. with some limited success. I have also tried gentian violet in years past, but it's very messy & stains. I am curious what my colleagues are doing to treat chronically macerated interspaces?


Tom Silver, DPM, Minneapolis, MN



Query: Off-loading the Second Toe 


What suggestions are there to off-load the second digit after a hallux amputation? I have tried orthotics, moldable custom silicone toe wrap, and different shoes. Any help would be appreciated.


Jeffrey Klirsfeld, DPM, Levittown, NY



Query: Unusual Pathogen in Paronychia


I received a culture report from a paronychia swab that grew a pathogen I have never encountered before. It is Leclercia adecarboxylata. It is sensitive to the usual antibiotics. Staph aureus (MSSA) was also in the culture. The patient is a healthy young man. I am wondering if anyone else has encountered this bacteria in a paronychia or other wound culture.


Howard E Friedman, DPM, Suffern, NY



Query: Fixation of 5th Metatarsal Osteotomies


In our practice, we most commonly perform a "Reverse-Austin" for Tailor's bunion deformities. Over the years, we have used K-wire, Orthosorb, and screw fixation for the distal V-shaped osteotomy. Most were done with a single tapered Orthosorb pin. I am looking for a small screw alternative. Our hospital encourages us to use the Synthes screw sets. We use 2.7mm fully-threaded cortical screws for our distal 1st metatarsal Austin osteotomies.


I am interested in learning what type of fixation my colleagues are using for distal 5th metatarsal osteotomies.


Greg Caringi, DPM, Lansdale, PA



Query: Cutting Edge Laser Technologies


I am considering getting into "laser technology". Has anyone dealt with "Cutting Edge Laser Technologies", a company out of New York? The salesperson basically says that this technology is great for post-op healing and acute pain, wound healing, neuropathy, and inflammatory condition, etc. It is not covered by insurance and I have concerns about the risk/benefit of including it in my practice which is financially strapped due to COVID-19. Both good and bad experiences would be appreciated.


Tip Sullivan, DPM, Jackson, MS



Query: Lengthening the Extensor Tendons with a Hammertoe Repair


I have a question about lengthening the extensor tendons with a hammertoe repair. From my education and experience, the extensor tendons to the lesser digits are elongated/stretched with the deformity and the flexor tendons contract/become tight. Shouldn't the flexor tendons be lengthened? I know this would have to be done cautiously in that over-lengthening the flexor tendon(s) would lead to decreased toe purchase, but I would like some other perspectives on this topic.


Anthony R. Hoffman, DPM, Oakland, CA



Query: Overlapping 2nd Toes, Bilateral in a 2 Year Old


This 2 year old is asymptomatic, but his mother is concerned about the condition getting worse. I'm looking for treatment options.


Overlapping 2nd Toes, Bilateral in a 2 Year Old


I'm already familiar with stretches, taping, toe spacers, and orthotics. Does anyone have other ideas? Would one ever consider surgery?



Query: Possible Post-COVID-I9 Pedal Pain


We have been seeing a number of patients in our office who have been presenting with unilateral foot and ankle pain in the soft tissues and joints. All tests including radiographs and bloods were normal. The only thing that they all have in common is that in March they had COVID-19 with minimal symptoms which included loss of taste and low grade fevers that lasted for 48 hours. The pedal symptoms and their histories of having COVID-19 might be purely coincidental or they may not be. Has anyone else come across this in their practices?


Elliot Udell, DPM, Hicksville, NY 



Query: Sea Urchin Injury


My daughter’s friend thinks she stepped on a sea urchin yesterday. I met her in the office today to exam her foot. She had several “spines” around her heel and 5th MPJ. Slight pain was noted around the MPJ area, but was improving. Some redness is noted but no temperature increase or red streaking is noted. She soaked her foot in vinegar for several hours. She did get a prescription from another friend’s father for Cipro. She is allergic to penicillin. The spines, as pictured below, are the diameter of a hair.


Sea urchin injury


I tried removing some of them but they are very fragile and break into smaller fragments. I didn’t want to anesthetize the multiple areas to remove them because I felt it would do more harm than good. I instructed her to get a tetanus shot if she is due and to take the Cipro as prescribed. I’m not sure if the small spines need to be removed. If anyone has experience with this, your input would be appreciated.



Query: Inferior Extensor Retinaculum


All DPMs are aware of and treat tarsal tunnel syndrome, either conservatively or surgically. I need some information on the inferior extensor retinaculum. I have a patient who gets a "severe stinger" in his right hallux when he wears socks that might constrict him at the ankles.


Upon examination, he has a distinct Tinel's sign during percussion of a certain spot at the anterior-medial ankle. Does anyone have experience with this type of condition, and is the algorithm of treatment similar to that of tarsal tunnel?



Query: Photodermatitis During Terbinafine Dosing


I am curious about whether the readership has any quantitative data or clinical experience regarding photodermatitis during terbinafine dosing. Is complete avoidance of sunlight necessary or is skin sensitivity related to time of exposure? Are there other factors that are contributory? Does sunscreen provide any or some protection from possible photodermatitis while taking terbinafine? Our southern California weather is sunny most of the time, so questions regarding sunlight effects and medication are especially pertinent.


Neil H Hecht, DPM, Tarzana, CA



Query: Phenol Injections for Neuromas


Due to the unavailability of sclerosing alcohol, I have been reading about phenol injections for neuromas.  Has anyone tried this method?


Karen Wasserman, DPM, Dallas, TX



Query: Panacos Procedure for Warts


For those who perform the Panacos procedure for warts, what is the longest anyone has seen results? The success rate is really high. The disadvantage with this procedure is that it takes months to work. I recently had 2 patients whom I did the procedures on a year ago but the warts have not resolved yet. I am wondering if there is still a chance for them to resolve. If not, I wonder what I might be doing wrong. I've been cutting out smaller lesions now, about 2-3mm to re-implant into the abductor hallucis muscle. Should they be larger?



Query: Bilateral Ankle Instability


I have a 16 year old patient who presents to see me regarding bilateral ankle instability and pain around the fibular malleolus from chronic sprains. She has a high arched foot structure and ankle equinus. She also has significant tibia varus and what may be impingement of the calcaneus on the fibula. I sent her to PT for strengthening and stretching but she has not seen much improvement of the area.


I have cast her for custom made foot orthoses but am unsure of the rearfoot posting. I believe that the calcaneus is a component of this problem and think a mild varus post would help decompress laterally, but I do not want to contribute to instability. Any thoughts or suggestions?



Query: Fireworks Foot?


Has anyone encountered pedal or lower extremity injuries from fireworks? If not yet, it will probably happen soon because the out-of-control use of these devices is no longer restricted to "fun and games" on the Fourth of July.


Elliot Udell, DPM, Hicksville, NY



Query: Unknown Hallux Lesion


I have a 40 year old male patient, no medical history with a great toenail that looks like half a Ping-Pong ball. No trauma, no pain, no infection, no discoloration, but in 2015 he tells me that it was much smaller. The toe was x-rayed and the nail removed for inspection. 


Unknown Hallux Lesion


The DP film shows a calcification channel from the grown into the 1st interspace. The lateral shows a very good outline of the growth as well. This patient does not have insurance, but will likely pay out-of-pocket for what I would expect to be a full excision as opposed to a punch biopsy. That discussion is pending a final diagnosis. Your thoughts are appreciated.



Query: Pre-Cancerous Skin Lesion

This 76 year old female has a past history of cancerous skin lesions. She has been seeing her dermatologist who initially froze this lesion twice with no improvement. A biopsy was performed and the only information I have is that the dermatologist told her it was pre-cancerous. 


(L-R) Pre-Cancerous Skin Lesion post- and pre-debridement


She uses urea 40% and covers it with a padded bandage. It is painful to touch and feels better if the hyperkeratotic skin is debrided. he photos are before and after sharp debridement. Has anyone seen a similar lesion? 



Query: Ultra-long Distance Injuries


One of my patients told me that he and his friends have "grown out of" marathon running. They are now called ultra-long distance marathons. He recently completed a 55 mile race. It goes over one or more days and, in some cases, the entire race takes place over a few days on an enclosed jogging circle. He has signed up for a six-day run. Has anyone observed any new pathology associated with patients participating in this sport?


Elliot Udell, DPM, Hicksville, NY



Query: Dr. Brown’s Treatment for Sciatica


I have read with interest the “out of the box” treatment for sciatica that Dr. Brown developed. What is the technique or where can I read up on this treatment?


Ivar E. Roth, DPM, MPH, Newport Beach, CA



Query: Treatment for Covid Toes


What is the treatment protocol for Covid toe? Is it self-limiting? How do you treat the symptoms of itching or burning sensation? What is the consensus for a treatment plan?


James Lucarelli, DPM, New Bedford, MA



Query: Covid Toes?


Below are pictures of two different patients who are brothers. The older one is 21 and the younger one is 17 and they were not tested for COVID-19. The younger one was massively exposed at school in early-mid March- a "cluster" according to mom, and apparently gave it to his older brother. The younger one had no symptoms and the older one had 99.5-100 temp for a week and the skin manifestations showed up 4-5 weeks later on them both. Three dermatologists, including the one running a COVID derm registry, said these lesions are even more definitive than a test, and the patient’s pediatrician diagnosed these two patients retroactively with COVID-19 based on their presentation.


Possible Covid toes of two brothers


It appears that many patients do in fact test negative for the virus as this is appearing to be more of a "post-infectious" phenomenon and if testing is going to be done on these patients, it should be for antibodies and not for the virus. I have had 5 patients over the past month and had them all tested for COVID-19 and they all were negative. I will now consider discussing antibody testing with them. Yes, I am aware that these lesions can be caused by many other infectious disease processes as well as other types of viral lesions, and a thorough history needs to be taken. I look forward to hearing from others regarding this.



Query: COVID Toes?


A patient presented with blistering, swelling, and erythema on the toes this week. She has had a history of Raynaud’s but had not had the degree of blistering that she presented with in my office in the past. She is a mother of two young children and the photo was taken when she was away on vacation domestically sometime in early February.




Had she had symptoms before the COVID-19 outbreak, my provisional diagnosis would have been escalation of her Raynaud’s with a differential diagnosis of some other rheumatological problem. She presented with no other symptoms, but given the number of COVID toe cases being reported, it crossed my mind as a remote differential. I would appreciate any thoughts from my colleagues.



Query: Sickle Cell Anemia and Peri Ankle Ulcerations

I have a 51 year old black male patient with sickle cell anemia who also has diabetes mellitus. The patient's blood sugars average about 190 and he was diagnosed about 7 years ago with DM. The patient periodically presents to see me with painful ulcerations, typically dorsally and laterally around the ankles often but not always unilaterally. 

Sickle Cell Anemia and Peri Ankle Ulceration

He develops atrophic punched out small crusting wounds which are very painful. He has had enough of these incidents to have developed scar tissue and skin discoloration around these areas. His pulses are strong and the skin temperature is normal and he has no loss of protective sensation. These seem to take a long time to heal and are quite painful. Comments on how to heal or prevent these ulcerations would be appreciated.



Query: Residual Club Foot Recommendations


This patient is a 31 year old female with residual clubfoot complications. She had Ponsetti-type treatment as an infant, and surgeries at 9 months, 9 years, and 12 years of age. She has lateral column overload, fibular impingement, deltoid insufficiency with talipes valgus and medial shift, severe forefoot varus/supinatus, and plantar subluxation of the TN joint with secondary adaptation. 


X-rays of residual clubfoot


By exam and x-rays, she has a large TC coalition. It appears the coalition went unrecognized and the previous treatments subluxed the ankle and TN joints to get a plantigrade heel. Orthotics with accommodative forefoot varus no longer help. I would value recommendations on surgical treatment. I am thinking about correctional TN arthrodesis, deltoid reconstruction, heel osteotomy vs. coalition resection plus a STJ correctional fusion. I still need heel axial x-rays. Would a CT be valuable in planning?



Query: Clinical Manifestations of COVID-19


Recently, I came across a patient with symptoms of pain, tingling, and redness to his toes. He attributed it to working out barefoot on a cement floor. The patient has no significant medical history. Has never had these symptoms prior and has no smoking history. Clinically, all 10 toes were cold to touch, with erythematous patches and minimal blistering, some toes had ecchymosis patches. He was recommended nitro paste, to wear socks, and to keep his toes clean and dry. 


A few days later, I came across an article depicting similar findings presenting in COVID-19 patients. I spoke with the patient and he continues to be asymptomatic for COVID-19, but has taken his father to the hospital for a presumed infection, hence his exposure. Incidentally, podiatrists can report similar cases to the American Academy of Dermatology registry.  

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