Podiatry Management Online


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From: Howard Dananberg, DPM


Considering that there is only minimal pain despite extensive palpation, but pain occurs with standing and/or walking, a herniated lumbar disk should be ruled out, particularly in light of the type of ski jump injury he incurred. A straight leg raise exam may reproduce symptoms. The other two problems may be 1) trigger points in the soleus which can cause referred pain to the inferior heel but would not exhibit symptoms on localized exam, and 2) a cuboid fixation, which can cause pain in the abductor hallucis muscle, often confused with plantar fascia pain.


In this situation, careful palpation shows limited to no pain with plantar fascia palpation, but when the abductor is palpated above the superior aspect of the plantar fascia, pain is acute. Manipulation of the cuboid creates spontaneous relief. I think that the disk herniation, considering the history of injury, is the most likely culprit.  


Howard Dananberg, DPM, Stowe, VT

Other messages in this thread:



From: Ron Werter, DPM


I once spent close to an hour removing about 15 spines from a patient. That being said, do a PT block so you block the heel with one injection instead of multiple ones. I would try to minimally debride around each spine and remove as much of the spine as possible as if you were enucleating a seed corn. 


They will not dissolve on their own. If you don't remove as much as possible, the body will encapsulate them and the patient will have small keratomas possibly at the sites.


Ron Werter, DPM, NY, NY 



From: Howard Zlotoff, DPM


My son is a pediatric dermatologist at the University of Virginia. I sent him this case and photo from PM News. His differential diagnoses include: neutrophilic eccrine hidradenitis, erythromelagia, dyshidrotic eczema, and mercury poisoning. He recommends consulting a pediatric dermatologist of course!


Howard Zlotoff, DPM, Mechanicsburg, PA 



From: Jesse Riley, DPM, Ben Cullen, DPM


I recommend Bleomycin injections. After having used everything else, they have given me the best results, are the least invasive, and are not very painful for the patient. You would want to shave down the superficial layers first, but then I would inject each lesion with Bleomycin reconstituted with 1% lidocaine with epinephrine.  An alternative to injecting is to do a “needle-free” version using a Madajet. It’s a great idea for kids, as it lessens the anxiety.


Jesse Riley, DPM, Evanston, WY


I recommend trying topical Imiquimod. I have had a couple of lesions that did not respond to months of various treatment measures and then were gone within a couple of weeks of applying this 3x/week at bedtime.


Ben Cullen, DPM, San Diego, CA



From: Name Withheld


I had a very similar situation. The patient was type 2 diabetic, 50 years of age, and had been seeing me for a plantar callus on his foot for two years. Conservative treatment consisted of Q 1-2 month debridement of his callus. I suggested orthotics and Spenco insoles with accommodation to off-load the callused area and overall decrease stress on his foot. 


In addition, I suggested and expressed importance of wearing proper fitting shoes. He consistently wore improper width shoes and sandals with no shock-absorbing insole. By not wearing at least OTC arch supports and...


Editor's note: To read this extended-length letter click here.



From: Win L. Chiou, PhD


About 50% of toenail disorders may be attributed to diseases mimicking onychomycosis. That includes the commonly occurring trauma due to the friction of the big toe against the shoe (M. A. J. Allevato, "Diseases Mimicking Onychomycosis", Clinics in Dermatology, 28: 164-177, 2010). Your patient’s hallux nails might be caused by footwear trauma. About a year ago, my two big toenails were injured by a metal bar, resulting in some dark bruises. Both nails stopped growing for about six months until I applied my Dr. Win’s Fungal Nail Therapy solution twice daily to the cuticle areas. Healthy nails quickly grew out in about five months, which was very quick considering my age of 77.


Disclosure: Dr. Chiou is President of Winlind Skincare.


Win L. Chiou, PhD, Burr Ridge, IL



From: Matthew Kaiman, DPM


Please refer the patient to a neurologist as the work-up for a radiculopathy appears logical in the absence of any additional information. It seems as if you have established a piece of the algorithm which is beyond the scope of your practice.


Matthew Kaiman, DPM, Englewood, NJ



From: Elliot Udell, DPM


We have all seen cases of recalcitrant heel pain in our practices, and we inevitably think: "what the heck am I missing?" It appears from the clinical description that the patient was thoroughly worked up and evaluated from  radiological, rheumatological and neurological perspectives, and no clinical diagnosis was obtained. What you might attempt is to treat this patient symptomatically with a combination of intensive physical medicine, such as interferential therapy, injection therapy which would include posterior tibial injections, strappings to off-load the plantar fascia, and oral non-steroidals.


The patient must be told that these conditions often take many weeks to totally heal and he or she should not expect "overnight" relief.  


Elliot Udell, DPM, Hicksville, NY



From: Peter Bregman, DPM


I am glad people are getting great response to the alcohol injections, but none of these doctors who state their great results have data to back them up. It's anecdotal. Perhaps, as I suggested, just try Marcaine by itself. I bet you get the same results as with the 4% alcohol. I used to use it myself so I can say I did not have the success that people claim to have.


I would really like for those who use the alcohol to try injections without it on the next 5 patients (with 2-4 milligrams of Decadron, if you like), and you will see the same results. Think about it - why does it take many injections for it to work? The small amount of alcohol will not cumulatively kill the nerve. It's too small a dosage...not to mention that diluting it in that bottle of Marcaine takes away a lot of the dehydration process.


Peter Bregman, DPM, Las Vegas, NV



From: Kevin Pearson, DPM


Having recently undergone knee surgery that required me to be non-weight bearing for 6 weeks, I have gained a new appreciation for what is required of a patient to be truly compliant. Although I am in good shape and not overweight, the crutches were killing me - not to mention how difficult they made it to walk.


I personally tried the Freedom Leg and found it to be a lifesaver. It is not for everyone. A patient needs to be somewhat physically fit and have great balance. Second, I recommend the patient gets it and trys it for a week or more prior to the surgery. Start using the brace and two crutches and as the patient's confidence grows, drop down to one crutch and then ambulate with only the brace.


Kevin Pearson, DPM, Stockbridge, GA



From: Dennis Shavelson, DPM 


This is the youngest case of “disappearing toenail syndrome” (DNS) I have seen. We all see these nails in practice at different stages, but they are especially problematic in the latest stage when the nailbed unit covers with stratum corneum as in this 4 month old.


Disappearing Nail Syndrome


I have developed a formula for a multimodal plan for care. It involves shoe modification, an adhesive or RockTape strapping that I have developed, cosmetic reconstruction of the nail and a NuVail Rx that works about 60% of the time in well selected cases. When this doesn’t work, I suggest plastic surgery or lifetime cosmetic toenail reconstruction.


Disclaimer: I am a consultant to Innocutis, the marketers of Nuvail (poly-ureaurethane 16%)


Dennis Shavelson, DPM, NY, NY



From: Keith L. Gurnick, DPM


"Conundrum" or difficult surgical decision? I agree this is a challenging patient as is often the case with most revision foot surgeries. The x-rays provided show marked narrowing of the 1st metatarsal-phalangeal joint space, but a fairly rectus or anatomic hallux position. You should consider the option of inserting a double-stem silastic/silicon implant such as either a Swanson or a Primus (with the metal grommets) which will help to prevent additional shortening of the hallux and allow a toe that will still bend with forward ambulation. 


However, these types of double-stem implants are subject to...


Editor's note: Dr. Gurnick's extended-length letter can be read here.



RE: Failed 1st MPJ Fusion

From: Peter J. Bregman, DPM


It depends on the ambulatory status of the patient as well as his bone stock and the reason the non-union occurred. Without knowing all of this, I recommend either trying to fuse the joint again using allograft from the calcaneus along with amniotic tissue graft and a different type of fixation (probably plate and screws), or utilizing a silicone double stemmed implant with grommets.  If you don't have enough length after the fusion, you can always do a distraction Calais procedure to gain proper length. If you are not adept with external fixation, find someone who is.


Peter J. Bregman, DPM, Las Vegas, NV



From:  Douglas Smith, DPM


I have seen several similar presentations which turned out to be candidal yeast infections. Occasionally, on avulsion of the nail plate, there may be some creamy discharge. I would avulse the nail plate, culture as appropriate, and start the patient on your usual post-avulsion routine, but use a topical anti-fungal such as econazole that also has activity against bacteria and yeast.


Douglas Smith, DPM, Raleigh, NC



From: Robert Kornfeld, DPM


While I completely understand the humiliation of being grossly underpaid, I am still confounded by the fact that it has gone this far. There's no question that there are many practitioners out there who have always tried to stay one step ahead of the "system" and have done their due diligence to stay in the black. But why should anyone need to work hard just to stay one step ahead? Why is it that so many have fallen prey to a system that consistently works against their success and still stay in the system? 


I saw the handwriting on the wall and left all of my participation agreements in...


Editor's note: Dr. Kornfeld's extended-length letter can be read here.



From: David T. Weiss, DPM


I feel compelled to comment on the inquiry regarding prolotherapy. This treatment has been helpful for me in treating many muskuloskeletal problems that we see as podiatrists. Simply put, prolotherapy counts on the body’s own ability to heal itself. I spent a lot of time with a physiatrist (MD) who helped me learn these techniques. My father was a chiropractor, and I have always kept an open mind to “alternative health techniques.” 


There are many types of injections that can be used to trigger a healing response in...


Editor's note: Dr. Weiss' extended-length letter appears here.



From:  Robert S. Schwartz, C. Ped.


To relieve her pain, try a rigid rocker sole shoe. This will stabilize and support the midfoot while reducing the demand for motion during the propulsive phase of gait. We use MBT shoes; and Finnamic as our go-to brands. There are others in the marketplace. Furthermore, almost any walking shoe can be customized to achieve this goal. Shock-attenuating plantigrade inserts should also prove effective.


Robert S. Schwartz, CPed, NY, NY



From: Eric Edelman, DPM


If it were my case and I "ran out" of posterior tibial tendon after removing the accessory navicular bone, I'd do one of these:


1. Place Krackow non-absorbable sutures into the proximal stump of the PT tendon and approximate to suture from a bone anchor you have inserted into the navicular. Close and cast in slight inversion.


2. FDL transfer.


In a 13 year old, I'd plan on a fiberglass cast for 4 weeks, a CAM-walker boot for 4 weeks, and then a lace-up sneaker or hiking boot with an orthotic with a medial flange for one year. 


Depending on what the rest of the foot and gait look like, a bone procedure could be appropriate, but your case sounds like a big piece of bone that's causing irritation, not painful flat feet.


Eric Edelman, DPM, North Syracuse, NY,



RE: Painful Stiff 1st MTP Joint After Bunionectomy with Implant (Mark Aldrich, DPM)

From: SJ Siegel, DPM

A weight-bearing lateral film would be helpful. Assuming there is no 1st ray elevation, I usually do manipulation under anesthesia in the office - Mayo block and aggressive distraction, and plantarflexory manipulation. I typically avoid intra-articular cortisone post MUA in joint replacement patients. I almost always prescribe a DynaSplint - it's expensive, but very helpful.


SJ Siegel, DPM, Bensalem, PA,



RE: Painful Stiff 1st MTP Joint After Bunionectomy with Implant (Mark Aldrich, DPM)

From: Randall Brower, DPM

The poor sesamoid complex always gets forgotten. If you Google "how many bones in the foot," only one site gets it correct by including the sesamoids. My point? When we do hallux limitus/rigidus surgery, many of us were taught to open the joint, take a McGlamry elevator and scoop the met head, releasing the sesamoids. This may give great intra-op ROM, but all we did is just create acute arthrosis of the 1st met/sesamoid joint. This creates stiffness of that joint until the sesamoids re-ankylose.

My hunch is, you have to keep the sesamoids in your differential; maybe take axial views of them, rule out arthritis, and then move on. Surgical scar/adhesions of the 1st MTPJ will not fix the problem if the sesamoids are arthritic.

Randall Brower, DPM, Avondale, AZ,


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