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Query: Severe Plantar Hyperkeratosis


This  59 year old male presented with extensive hyperkeratosis, bilateral and symmetrical on the plantar aspect of the heel as well as its periphery. He also has global forefoot keratoma and digital keratoma. His medical and surgical history is unremarkable. He has a cavus/supinated foot type, which is causing some of the hyperkeratosis formation. He states that this condition started about three years ago, with bilateral changes to his nails on the feet and hands (no callus to the palms). Nails and callus have a yellow/brown discoloration.

Severe Plantar Hyperkeratosis (after debridement)


Treatment has consisted of debridement of the calluses. I've discussed with him the possible advantage of orthotics, based on foot type and biomechanics. A dermatologist simply prescribed a hydrocortisone ointment that softened the lesions enough that he could attempt self-care. Any advice would be appreciated. 

Other messages in this thread:



Query: Unusual B/L Heel Pain Case


A 58 year old Indian male presented with B/L symmetrical plantar heel pain with a sudden onset 5 months ago. The pain is severe with any type of pressure. He has a severe pes planus foot type. Current treatments include EPAT x 2 and a Medrol dose pack, which he has not responded to. The rheumatology blood test panel revealed positive ANA, homogenous, 1:80 titer. The rheumatologist consulted believed that the titer was too low, so therefore not auto-immune related.


Lateral X-Ray of Patient with Bilateral Heel Pain


The patient had similar pain 9 years ago and then failed attempted treatments including: custom orthotics, cortisone injections x 2, EPAT x 4, e-stim x 6, acupuncture, PRP, stretching, icing, and reflexology. The pain seemed to resolve at that time on its own and not as a result of any treatment. Comments?



Query: Unilateral Edema, Redness, and Pain 


A 65 year male with a PMH of neuropathy, Stage 3 chronic renal failure, thyroid goiter, and ulcerative colitis presented with 2-3 months of swelling, redness, and pain to the entire left foot from the toes to the ankle. There is no allodynia or hyperesthesia. Calor, edema, and redness are worse at the 3rd met head, spreading to the 2nd and 4th met heads. His pain is concentrated in those areas.  


Yet, x-rays and MRI only show severe arthritic changes to the 1st MTPJ, while the areas of pain only revealed edema to the dorsum soft tissue. There are no soft tissue lesions or bony lesions. I thought it was unusual to have worse pain, warmth, redness, and swelling away from the arthritic area if the arthritic area was the cause. I told him to compress and elevate the foot. Any other thoughts? 



RE: Congenital Malalignment of Hallux Toenail

From: Chris Seuferling, DPM


Thanks to PM News and Dr. Allen Jacobs, I am now aware of this diagnosis and have seen multiple cases over the past year. This is likely an under-diagnosed pathology in our profession. The challenge now is treatment. I have not been able to find any podiatrists or surgeons in my area who surgically treat this condition with the nail rotation procedure described in the literature. 


Congenital Malalignment of Hallux Toenail


I'd like to learn how to perform this procedure so I can offer this to my patients. I’m looking for someone who has performed this procedure and possibly has video on technique. Any help would be appreciated.


Chris Seuferling, DPM, Portland, OR



Query: Stucco Keratosis


Does anyone know of any cures for stucco keratosis or what they found that works best for this condition? The patient was diagnosed by a dermatologist and was prescribed a very expensive cream that did not work. The patient is healthy, is in her 40s, and gets self-conscious about how it looks. She has been using Gold Bond Rough and Bumpy Skin which seems to have helped, where the lesions are now hardly noticeable. 


Stucco Keratosis


I have not heard of any oral medication for this, but would like to know if there is such a thing. The lesions do not hurt or itch.    



Query: Restless Legs Syndrome (RLS)


I had a simple case scheduled in the OR this week and ran into a complication I had not seen previously. I suspect we have all had restless patients on the table, but I had a patient so agitated that we had to convert to LMA anesthesia before any prep or draping due to the almost violent movement of both of her arms and legs. Other than some IV sedation, there was no noxious stimuli to explain her reaction.  


Once in PACU, the patient explained that she has suffered from this problem for years. She says she cannot sleep at night because of it despite her regular use of ropinirole. Since her primary seems to have ignored the severity of this problem, I want to help my patient by referring her for a specialist consult. I'm not sure where to send her - neurology, pain management? I admit to having very limited knowledge of RLS.  Any input is appreciated.



Query: EpiFix Micronized Amniotic Membrane


I am interested in hearing from physicians who are using EpiFix Micronized amniotic membrane allograft for plantar fasciitis as to what type of results they are seeing. Apparently, there are no procedure codes for this allograft; however, the company suggests Q4145. They charge the physician $1,000 for 40 mg. product size. Are any insurance companies paying for this procedure and if so, what is the reimbursement rate? Any other options for non-viable cellular membrane allografts?  


Paul A. Galluzzo, DPM, Rockford, IL



Query: Can These Toes be Saved?


This 66 year old male had the following co-morbidities: Coumadin necrosis as per bone biopsy, diabetes, heart condition, and is post-stroke. Surgical history: left and right hallux partial amputations, a partial amputation of his right 2nd toe, and his left 2nd toe was amputated due to osteomyelitis with MSRA. His treatment included IV antibiotics, hospitalizations, hyperbaric oxygen therapy, off-loading, and vascular surgery.


Can These Toes be Saved?


When the left 3rd toe had surgery and primary closure, the toe did not heal and kept getting worse. He finally had an endovascular specialist perform a surgical procedure to attempt to improve blood flow. The specialist’s opinion was that there was a "window of opportunity for a transmetatarsal amputation." Any opinions on if any of the toes can be saved?



Query: Calcaneal Avulsion Fracture


This is a 37 year old patient who was walking rapidly yesterday. He said he turned to change directions and felt a horrible pain in his heel. He has a significant medical history of a  motorcycle accident approximately a year ago with multiple fractures of the contralateral limb, but there was no trauma to the limb involved today.


Calcaneal avulsion fracture


It's rare to see avulsion fractures of the plantar fascia attachment. Achilles attachment avulsions are more common in about 1% of calcaneal fractures. The question is surgical repair or no surgical repair? It is almost asking for a percutaneous screw.



Query: Lateral Column Fusions vs. Arthroplasties of the Metatarsal Cuboid Joints


I have an active slightly overweight active middle aged female patient with a non-contributory medical history who has developed painful osteoarthritic changes across the Lisfrancs joint involving 2nd met/cuni, 3ed met/cuni, 4th met/cub and 5th met/cub. Conservative treatment has failed to give her significant relief of pain. She gives no history of acute trauma recently or in the past. On clinical evaluation, the majority of pain is produced with range of motion/stress of the 2nd and 5th metatarsals at the base. Her forefoot to rearfoot is slightly varus. She has a cavus foot type.


AP and oblique views


These are well aligned joints, just arthritic and painful. I am concerned about fusion of the 4th and 5th metbase/cuboid in this foot because of the independent motion required by the lateral column. I was thinking about cleaning up the 4th and 5th met/cuboid joint and placing a joint spacer there to maintain some motion. I would appreciate comments on lateral column fusions vs. arthroplasties of the metatarsal cuboid joints.



Query: Best Way to Test for Onychomycosis


Should nail cultures be performed on all possible fungal nails, and if so, what type of culture? Is it best to use a lab or perform the test in-office?  


Martin Marks, DPM, Compton, CA



Query: Botox for Plantar Fasciitis


Does anyone have any experience with injecting Botox or Dysport for plantar fasciitis? The research I've seen seems to be promising. Just wondering if anyone has recommendations or any pros or cons about using it. 


Rosemarie Caillier, DPM, Tuscaloosa, AL



Query: DVT Following Use of Rolling Knee Scooter?


I treated a patient with a rolling knee scooter for a ligament tear in conjunction with a CAM walker in an otherwise healthy moderately overweight non-smoking patient. He returned after about 2-3 weeks of use with swelling of the foot and lower leg. The initial ultrasound was negative for DVT. A week later, a repeat test was positive for a femoral DVT. I have seen only one anecdotal report of a DVT following use of a knee scooter and one article suggesting it as a possible complication. Yet, the timing seems too coincidental not to be directly causative. Have colleagues seen this complication in patients who have used knee scooters?



Query: Treatment of a Verrucae in a 3 Year Old


My patient brought in her grandson to look at a lesion on the bottom of his hallux in the skin fold area at the IP joint. It is very typical in nature characteristic of a verruca...interrupted skin lines, capillary budding, pain mostly with lateral pressure, etc. It has been present for about one month and is around 5-6 mms in diameter.


 Verruca in a 3 year old


Instead of the dreaded paste application again and again, would Cantherone or a similar one-time application of a product be contra-indicated because of the patient's age? I do realize it will be uncomfortable as the blister forms, but it might be the best treatment to avoid repeated trips to the office and a real possibility of childhood fear of that type of recurring treatment. Any suggestions would be appreciated.



Query: 5th Met Head Transplant for Freiberg's Infraction


I am wondering how our colleagues are handling painful, unstable, 2nd MPJ due to Freiberg's infraction. Many years ago, a colleague of mine would transplant the 5th metatarsal head to the second MPJ. Does anyone still do this and is there any literature on this? 


Norm Wortzman, DPM, Boston, MA.



Query: Ingrown Toenail on a 6 Month Old Boy


A 6 month old baby boy presented with a chronic paronychia and onychocryptosis to both big toes at the medial corners. The R big toe has a lot of granuloma and is enlarged at the tibial corner. PMH: He was a month early in birth. Otherwise, he is healthy and has no developmental issue.  


Ingrown Toenail on a 6 Month Old Boy


I would like to do a matrixectomy to remove the offending borders. The procedure would be under general anesthesia. I am leaning toward the cold steel nail procedure vs. the phenol and alcohol procedure. I would love to hear the pros and cons to the treatment plan you have in mind for this particular baby boy. 



Query: First MPJ Fracture Dislocation


I am looking for some insight in treatment/surgical planning for this 51 year old male who sustained a first MPJ fracture/dislocation 2 months ago. He was never treated and came to me with pain plantarly at the first metatarsal head and sesamoids with ambulation and palpation, as well as the hallux dorsally displaced 1.5 to 2cm. from the WB surface. The hallux IPJ is mildly contracted dorsally, but currently not painful with shoe pressure. 


First MPJ Fracture Dislocation (oblique view)


Radiographically, the sesamoid fractures are apparent but they are not widely separated; therefore the intersesamoidal ligament is likely intact. The hallux looks only dorsally subluxed vs. dislocated. MRI confirmed that the flexor hallucis brevis is intact, but thinned at its distal insertion. Closed reduction failed, as expected. I have considered a plantar approach to excise the distal sesamoid fragments and attempt to repair the flexor with a Mitek anchor, or a combination of a complete removal of both sesamoids and fragments with a hallux IPJ arthrodesis with or without a total first MPJ Silastic implant to allow better reduction. All suggestions are welcome.



Query: Correcting an Excessively Long Toe


I have a patient with an exceptionally long 2nd toe that needs to be shortened. The toe is not contracted but juts out excessively and is painful. In the past, in correcting long toes, I have had a problem with cosmetic appearance due to excess skin once the toe is properly shortened. I have at times removed a large wedge of skin of the dorsal aspect of the toe, but sometimes this causes the toe to pull upwards.  


I know this problem isn't unique, as I have a few patients that had long toes corrected by other podiatrists who now have what they call their "Shar Pei" toe because of the accordion-like wrinkles in the skin. Any ideas on how to correct an excessively long toe with a good cosmetic appearance afterwards?



Query: IM angle correction from Austin Bunionectomy

From: Greg Caringi, DPM


I understand that it is the lateral displacement of the distal capital fragment that effectively reduces the gap between the metatarsals, but it does not directly reduce the IM angle. With improved overall alignment of the soft tissues, an acceptable cosmetic and functional result is obtained without the potential drawbacks of proximal osteotomies/fusions.


My question deals with the length of the dorsal arm of the osteotomy. Although many believe that the degree of correction improves with a longer arm, I know that there have been papers published that refute this idea, stating that the long arm simply facilitates rigid internal fixation with screws. I am asking my colleagues their opinion on the long dorsal arm. Does it help with IM correction? Can anyone supply references that address this subject?  


Greg Caringi, DPM, Lansdale, PA



Query: Pain 2nd MTPJ S/P Weil Osteotomy


A 61 year old female presented with pain at the dorsal lateral aspect of the left 2nd MTPJ, which has been increasingly symptomatic for the past 6 months. Direct palpation and attempts to dorsiflex the MTPJ exacerbate the condition. The patient is S/P a Weil osteotomy with arthrodesis of the left 2nd PIPJ  1-1/2 years ago.


Pain 2nd MTPJ S/P Weil Osteotomy


X-rays reveal arthritic changes with lateral subluxation of the left 2nd toe. I am considering a left 2nd proximal phalangeal base resection. I welcome any recommendations for treatment that may ensure the best possible outcome for the patient. 



Query: Pediatric Nail Deformities


An otherwise healthy and well-developed 9 month old baby girl presented with unusual nail deformities involving all 10 toes. No pain or infection was present. 


Pediatric Nail Deformities


Are there any congenital or metabolic conditions that would produce this deformity?  What is the prognosis?  What would this be called and how would you best treat it? I advised cutting the nails straight-across and massaging the nails after bathing with an antibiotic ointment.



Query: Allergic to Orthotics


A patient returned for a follow-up visit post-orthoses dispensing and stated that he "must be allergic" to the orthoses as after a few days, his feet developed a pruritic rash. Other than the possibility of hyperhidrosis and/or a reaction to the glue utilized to adhere the Naugehyde top cover to the thermoplastic orthtoic material, I am at a loss to explain this. Can anyone provide a possible cause and perhaps even a "fix"?  



Query: Severe Hyperhydrosis of Feet Affecting Bunion Surgery


I have a patient who is considering bunion surgery. On her initial exam, beads of sweat started forming and dripping from her feet within seconds of removing her shoes and continued through the entire appointment. She used to have this problem in her hands and feet. 30 years ago, all types of topicals were prescribed and used with no results. She had a surgical procedure performed which ended her hand perspiration, but not in her feet. My question is should the bunion surgery take place without addressing the hyperhidrosis? She is otherwise healthy, no meds, allergies or other relevant PMH, with no lower extremity vascular issues.



Query: Puncture Wound


A 13 year old female presented with a 3-4 week old puncture wound on her posterior heel. It is painful with no signs of infection. She was barefoot and stepped on a clean doorstop screw at a friend’s house. According to the patient, the screw only punctured superficially. Her PMH was unremarkable. The dermatological exam was unremarkable other than a local epidermal slough. There was no erythema or edema, and no signs of entry, but the area was very painful to direct pressure 2cm peripherally. X-rays were negative for any retained foreign body. I started her on Keflex, 250mg, QID and have her non-weight-bearing. Any other thoughts would be appreciated.



Query: Achilles Tendonitis with Partial Tears in a Professional Basketball Player

I’m seeking advice regarding best care for a professional basketball player who suffered an injury to his Achilles tendon. An ultrasound was done and the report said "tear of 50% of the Achilles tendon." He now is able to ambulate and play without pain; however, given the extent of injury, he asks whether he should have it surgically addressed. He also has flat feet that we intend to address with custom orthotics. His x-rays are unremarkable and the MRI report is as follows: 

  • 1. Low-grade partial-thickness interstitial tear of the Achilles tendon extending to its insertion. Mild tendinosis of the Achilles tendon.

  • 2. Mild plantar fasciitis.

  • 3. Mild scar remodeling of the medial and lateral ankle ligaments from chronic low-grade partial-thickness tear.

  • 4. Tendinosis with possible low-grade partial-thickness tear of the peroneal brevis tendon.

  • 5. Mild tendinosis of the posterior tibial tendon at its insertion. Mild tenosynovitis of the medial flexor tendons.

  • 6. Moderate size ankle joint effusion.

Should he be evaluated for surgical intervention? 



Query: Silicone Injections for Fat Pad Atrophy


Does anyone have experience with silicone injections for fat pad atrophy? If so, what has your experience been?


Frank DiPalma, DPM, Athens, GA

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