Podiatry Management Online


Podiatry Management Online
Podiatry Management Online



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RE: Chronic 1st MPJ Pain (Don Peacock, DPM)

From; Scott Hughes, DPM

I assume Dr. Peacock shared his pre- and post-op x-rays to show the success of his MIS technique.  I think most of us would agree that decompressing the 1st MPJ by shortening and plantarflexing the 1st met head is desirable for hallux limitus. However, the osteotomy, besides being inherently unstable and an elevatus waiting to happen, is oriented to create lengthening. Also, the osteotomy creates a plantar shelf directly above the sesamoids.

I am happy to hear the patient is pain-free, but when I look at this case, my thought is 'better lucky than good' rather than MIS is a viable alternative.

Scott Hughes, DPM, Monroe, MI,

Other messages in this thread:



RE: Severe Heel Pain After Plantar Fasciotomy (Mark Aldrich, DPM)

From: Peter Bregman, DPM

In order to rule out or rule in nerve pathology, I recommend doing a diagnostic block using no more than one cc of lidocaine plain in the medial calcaneal nerve and lateral plantar nerve separately. This may or may not be assisted by ultrasound. You can also look for a Tinel's sign with both these nerves as well. This will help make the diagnosis of a nerve problem versus something else.

Peter Bregman, DPM, Las Vegas, NV,



RE: Fissuring Under 4th and 5th Digits

From: Barry Mullen, DPM

From the brief history given, the congenital issue is likely a coincidence for my initial thought is infectious etiology, not mechanical/strutural. Dermatophytes and Candida are notorious for causing interdigital fissuring, especially between 4th toe webs, toe creases, especially in moist environments, i.e. the patient's swimming history. Included in your patient's history is a 2-3 time/year recurrence, likely representing next generation spore germination and re-start of the infectious process. If it were a mechanical etiology, it would likely be constant all year round.

Consider empirically starting your patient on OTC bid topical fungicides, then switching to a broad spectrum Rx if no response in 3 weeks. Ensure that Rx covers Candida. If still no response, take a shave biopsy and submit for analysis as erythrasma and white psoriasis can also present this way. Pending biopsy result, if infectious, yet unresponsive to appropriate topical agents, you may also need to consider an oral agent, particularly for recurrent/resistant cases. If you want to initially avoid the minor surgery, a Wood's light may shed light on the etiology (no pun intended). Once infectious etiology is ruled in, then also follow through with patient education on the benefit of consistent shoe sanitizing, as well as the various hygiene adjustments your patient can undertake that protects toe creases from additional exposure.

Barry Mullen, DPM, Hackettstown, NJ,



RE: Non-Specific Bone Marrow Edema Syndrome

From: Pat Caputo, DPM

The radiologist might be spot on. "Non-specific bone marrow edema" is also called transient or migratory regional osteoporosis. Certainly, her age group is not discussed in the literature, so a pediatric rheumatology or better yet endocrine consult is very highly suggested, especially in the absence of trauma. In the meantime, I would treat it like a Sudeck's atrophy or early AVN; and tell her it may take months, which is why the radiologist said to follow up with an MRI in 3 months. When the patchy MR presentation resolves, so do the symptoms. She is at risk for fracture in the short term, in addition to pain.


I had "bone marrow edema" in my early 40s in one hip and then the other, and 10 years later in one shoulder and then the other. I did a fair amount of research which included anecdotal discussions with some prominent endocrinologists from Johns Hopkins and UPENN as well as a prominent musculo-skeletal radiologist from Jefferson Med in Philadelphia. I was treated in the shoulders with IV Aredia. I'm not sure if it helped, as it still took months to run its course. It is more common in middle age men and pregnant women, so again I would definitely do a diagnostic work-up on the teenage girl.


Pat Caputo, DPM, Holmdel, NJ,



RE: Post-op Varus (Joshua Kaye, DPM)

From: Tip Sullivan, DPM

These feet always seem to be difficult to get right. I have adopted a simple attitude which I am sure will illicit different opinions. When in doubt—fuse it. I would also have corrected the transverse plane problem of the lesser digits in some fashion. To look at this problem as the lesser digits pushing the hallux back into varus is way too simplistic.

This is an issue that is based in biomechanics, and until you understand the biomechanics behind it, you are going to have trouble with surgical outcomes—especially long-term. This deformity is based in the mid or rear foot, if not higher. The real difficult thing is addressing this component in a 70+ year old person and keeping the morbidity as low as possible. As usual, it goes back to the risk/benefit ratio.


Tip Sullivan, DPM, Jackson, MS,



RE: Efficacy of Lasers for Onychomycosis

From: Robert Kornfeld, DPM

The obsession with therapeutics, whether laser or not, obscures a more important issue that is getting no attention here...i.e. WHY do patients have onychomycosis? What are the underlying mechanisms? I think we can all agree that even post-avulsion, most toenails will grow back with fungus. The purely local application of therapy is not reliable. Oral drug therapy is not reliable. What does this tell us? No amount of "evidence-based" trials are going to reveal the reasons why focusing on the symptom alone fail most of the time.

Suffice it to say that identifying the reasons why patients are prone to parasitic infections, have misdirected immune systems or burdens on their physiology should be the focus of our attention. I will say that the combination of local laser therapy along with a functional medicine approach to the patient-specific mechanisms (causes) of fungal disease nets the best rational and proactive approach. I have observed the efficacy of these protocols for years with long-term improvement.

Robert Kornfeld, DPM, Manhasset, NY,



RE: Numbness in Foot When Driving (Olga Luepschen, DPM)

From: Joel Lang, DPM, Al Musella, DPM

I suggest you investigate his driving seating position for possible pressure on the sciatic nerve or venous return. In addition, I would look at possible venous incompetency, causing swelling and pressure in his shoe when his foot is dependent and not moving much. Finally, check the shoe fit to see if it is too small and may not be able to accommodate the possible expansion of the dependent and relatively inactive foot. Sometimes, when we hear hoofbeats, we need to think "horses", not "zebras."

Joel Lang, DPM (retired), Cheverly, MD,

He probably has lost his fat and muscle padding over the sciatic nerve and the car seat is compressing it. Examine the position he is in when driving. Try adjusting the angle and height. Try this gel cushion:

Make sure he doesn't have his wallet in his back right pocket.


Al Musella, DPM, Hewlett, NY,



RE: Fixation vs. Non-Fixation of Metatarsal Osteotomies (Gino Scartozzi, DPM)

From: Elliot Udell, DPM


Arguing the pluses and minuses of minimal incision surgery in this day and age is akin to rehashing the merits of the Civil War in 2013. Both are old news. When it comes to the concept of minimal incision surgery, we are no longer talking about an exclusive podiatry topic. Today, the rest of the medical surgical world is performing surgeries with minimal incisions and promoting it in their advertisements.

There are minimal incisional spinal procedures, herniorrophies, gall bladder removals, and knee procedures. I even heard an advertisement on the radio today of a hospital doing cardiac bypass procedures utilizing minimal incisions. The days when patients would leave a hospital with "train track incisions from "head to toe' are long gone. My only question is whether podiatry had any significant impact on the minimal incisions surgeries done by the rest of the medical profession. 

Elliot Udell, DPM, HIcksville, NY,



RE: Elongated Halluces (Charles Morelli, DPM)

From: Joshua Kaye, DPM 


I was surprised to read the suggested treatment by Dr. Morelli for an elongated hallux. Considering that  he mentioned that the patient is a “young lady”, I cannot understand the rationale for the fusion of a functional and asymptomatic IP joint of the hallux when several other effective and function-preserving procedures are available. Perhaps he can indicate his reasoning.


Joshua Kaye, DPM, Los Angeles, CA,



RE: Lesions in Feet of Diabetic with Pancreatic CA (Larry Aronberg, DPM)

From: Arthur Gudeon, DPM, Neil A Burrell, DPM

My wife, Susan,  sadly passed away from this dreaded disease last week, after over a 29-month battle. During her courses of radiation and chemotherapy protocols, at various times, she developed those very same skin "rashes" pictured. They were neither painful nor pruritic, and always resolved spontaneously after a few days, or occasionally after a couple of weeks. Our  oncologist told us there was no need to bother Sue with biopsies, as there would be no change in therapy in any case, and the skin situation never became a problem.

Arthur Gudeon, DPM, Rego Park, NY,

Looks like tinea, old fashion "ringworm." I would use an anti-fungal for a month. His immune system is suppressed from the chemo. I would not worry about absorption. This patient is sick and I don't think you can make him any more sick with an anti-fungal. 

Neil A Burrell, DPM, Beaumont, TX,


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