General

  • Venous Stasis

    Venous stasis refers to loss of proper function of the veins in the legs that would normally carry blood back toward the heart. This may occur following injury to the veins, which can result in blood clots in the superficial veins known as superficial phlebitis, or following blood clots in the deep veins known as deep venous thrombosis. Swelling in the lower legs and ankle can also occur as a result of heart disease called Chronic Congestive Heart Failure and due to kidney disease. In some instances the cause of the swelling may not be easily identified.

    Diagnosis

    Individuals with this condition usually exhibit edema, which means swelling, of the legs and ankles. The superficial veins in the legs may be varicosed, causing the veins to be enlarged and appear as a cord or a bunch of grapes. Patients often complain of a feeling of fullness, aching, or tiredness in their legs. These symptoms are worse with standing, and are relieved when the legs are elevated.

    As the condition progresses the blood continues to collect in the feet, ankles, and legs. The pigmentation from the red blood cells stains the skin from the inside, and a reddish-brown discoloration develops on the skin. This is called venous stasis dermatitis.

    In severe cases of long-standing venous stasis, the skin begins to lose its elasticity, and a sore may develop on the inside of the ankle. This is known as venous stasis ulceration.This ulcer often will drain large amount of fluid and will have a red base. Secondary infection can complicate the ulcer and will require antibiotic treatment.

    Further testing may be requested by your doctor to further evaluate the condition of your veins. This may include venous Doppler testing, which uses sound waves to listen to the blood flow through the veins. If there is a suspicion of an acute thrombosis (blood clots), avenogram may be requested. This enables the veins to be visible on x-rays, and the blood clot can be identified with greater certainty. Identification of deep vein thrombosis is important, because failure to properly treat may result in a blood clot breaking loose in the leg and traveling to the lungs called pulmonary embolus, which can be fatal.

    Treatment

    The most common treatments for venous stasis are rest, elevation, and compression stockings. When elevating your feet the ideal position is to have your feet above the level of your heart. This permits greater return of blood back toward the heart. This usually means you are lying down with your legs raised with pillows.

    The compressive stockings come in different lengths. A knee high stocking may be sufficient if the swelling is confined to the lower legs and ankles. However if the swelling extends up to the knee, then a thigh high or panty hose style elastic stocking may be required. The compression stockings are also available in a variety of compression strengths. The greater the compression the more squeeze the stocking will apply to the leg. Generally, over-the-counter elastic stockings are available (without prescription) in most pharmacies or surgical supply stores. These have a compression range of 10 to 20 mm compression. If these do not provide enough compression to control the edema, then a prescription compression stocking may be necessary. These begin at 30 to 40 mm compression, and are often referred to as T.E.D. stockings. In more severe cases a higher level of compression may be necessary. These stockings often need to be custom sized to each individual leg, otherwise they are difficult to put on and may not provide even compression throughout the extremity. Your doctor may also use medications to reduce the swelling called Diuretics. Diuretics increase the output of urine and your doctor should closely monitor the use of this medication. If the cause of the swelling is due to heart problems or kidney problems your doctor will evaluate the need to adequately treat these conditions.

  • Ultrasound Examination Of The Foot And Ankle

    Musculoskeletal ultrasonography is a very powerful diagnostic tool for the diagnosis of wide array of foot and ankle problems. Your physician may order an ultrasound or perform the ultrasound in their office to help diagnose your foot problem. Ultrasound is used typically for soft tissue problem, not bone conditions. Some of the foot disorders that ultrasound is used for are the following:

    1. Foreign bodies
    2. Morton's neuroma
    3. Soft tissue masses
    4. Bursitis or capsulitis of the joints
    5. Ligament injuries
    6. Tendonitis or tendon tears
    7. Heel spurs or plantar fasciitis
    8. Tarsal tunnel syndrome
    9. Ultrasound guided injection or aspirations

    What is Ultrasound? Most people know about ultrasound to image a baby or a gallbladder, but it has growing application in musculoskeletal disorders. Ultrasound is based on sound waves. Sound waves are emitted from a transducer probe that is applied to the body and these sound waves will past into the body and then are reflected back to the transducer probe to be recorded. The recorded image is based on the density of the object that the sound waves encounter. An object with a high density appears white or brighter on the recorded image, while objects of low density will appear black or dark on the image. Intermediate densities will appear gray. The sound waves are recorded back to the machine, which will produce the image. This image will appear on the computer screen and is recorded permanently either by a hard copy film or video tape (if available) or both. A radiologist or your doctor will read these images and write a report on their findings.

    Ultrasound is completely safe and painless. It also has no contraindications. There is no problem in having the examination if you are pregnant, have a pacemaker, or other medical conditions that may prevent you from having a MRI or CT scan. Ultrasound also does not produce any radiation as with a CT scan or x-rays.

    In preparing for the examination, you can eat and take your normal medications. The examination will take from 45 minutes to an hour based on the area being scanned. It is advised that you bath the day of the examination but avoid the use of any skin lotions or emollients. Also you should where loose fitting clothing or shorts to make it easier to perform the examination. Your physician will discuss the results with you. If you have any further questions regarding why this test was ordered for you, please ask your physician.

  • Tips For The Diabetic Patient

    Ulcerations, infections and gangrene are the most common foot and ankle problems that the patient with diabetes must face. As a result, thousands of diabetic patients require amputations each year. Foot infections are the most common reason for hospitalization of diabetic patients. Ulcerations of the feet may take months or even years to heal. It takes 20 times more energy to heal a wound than to maintain a health foot.

    There are two major causes of foot problems in diabetes:

    1. Nerve Damage (neuropathy): This causes loss of feeling in the foot, which normally protects the foot from injury. The protective sensations of sharp/dull, hot /cold, pressure and vibration become altered or lost completely. Furthermore, nerve damage causes toe deformities, collapse of the arch, and dry skin. These problems may result in foot ulcers and infections, which may progress rapidly to gangrene and amputation. However: Daily foot care and regular visits to the podiatrist can prevent ulcerations and infections. 
       
    2. Loss of circulation (angiopathy): Poor circulation may be difficult to treat. If circulation is poor gangrene and amputation may be unavoidable. Cigarette smoking should be avoided. Smoking can significantly reduce the circulation to the feet significantly. There are certain medications available for improving circulation (Trental) and by-pass surgery may be necessary to improve circulation to the feet. Chelation therapy is an alternative form of treatment for circulatory problems that is not well recognized by the medical community at large. Daily foot care and regular visits to the podiatrist can often prevent or delay the need for amputation.

    Do the Following to Protect Your Feet

    1. Examine Your Feet Daily

    • Use your eyes and hands, or have a family member help.
    • Check between your toes.
    • Use a mirror to observe the bottom of your feet.
    • Look for these Danger Signs: 

               Swelling (especially new, increased or involving one foot)
               Redness (may be a sign of a pressure sore or infection)
               Blisters (may be a sign of rubbing or pressure sore)
               Cuts or Scratches or Bleeding (may become infected)
               Nail Problems (may rub on skin, cause ulceration or become infected)
               Maceration, Drainage (between toes)

      If you observe any of these danger signs, call your podiatrist at once.

      2. Examine Your Shoes Daily

    • Check the insides of your shoes, using your hands, for: 

               Irregularities (rough areas, seams)
               Foreign Objects (stones, tacks)

      3. Daily Washing and Foot Care

    • Wash your feet daily.
    • Avoid water that is too hot or too cold. Use lukewarm water.
    • Dry off the feet after washing, especially between the toes.
    • If your skin is dry, use a small amount of lubricant on the skin.
    • Use lambs wool (Not cotton) between the toes to keep these areas dry.

      4. Fitting Shoes and Socks

    • Make sure that the shoes and socks are not to tight
    • The toe box of the shoe should have extra room and be made of a soft upper material that can "breath"
    • New shoes should be removed after 5-10 minutes to check for redness, which could be a sign of too much pressure: if there is redness, do not wear the shoe. If there is no redness, check again after each half hour during the first day of use.
    • Rotate your shoes
    • Ask your podiatrist about therapeutic (prescription) footwear, which is a covered benefit for diabetic patients in many insurance plans.
    • Tell your shoe salesman that you have diabetes.

      5. Medical Care

    • See your podiatrist on a regular basis
    • Ask your primary care doctor to check your feet on every visit.
    • Call your doctor if you observe any of the above danger signs.

      Do Not Do These Dangerous Acts

      • Do Not Walk Barefoot - Sharp objects or rough surfaces can cause cuts, blisters, and other injuries.
      • Do Not Use Heat on the Feet - Heat can cause a serious burn, especially if the patient has neuropathy.
      • Do Not Apply a Heating Pad to the Feet
      • Do Not Soak Your Feet in Hot Water
      • Do Not Use Chemicals or Sharp Instruments to Trim Calluses - This could cause cuts and blisters that may become infected.
      • Do Not Cut Nails into the Corners - cut nails straight across.
      • Do Not Smoke - smoking reduces the circulation to your feet.
  • The Ischemic Foot

    The term "ischemic foot" refers to a lack of adequate arterial blood flow from the heart to the foot. There are a wide variety of possible causes for poor arterial circulation into the foot including arterial blockage from cholesterol deposits, arterial blood clots, arterial spasm, or arterial injury. The ischemic foot is also referred to as having arterial insufficiency, meaning there is not enough blood reaching the foot to provide the oxygen and nutrient needs required for the cells to continue to function.

    Diagnosis

    The result of insufficient blood supply to the foot can manifest itself in a variety of ways depending upon how severe the impairment to circulation. Early symptoms may include cold feet, purple or red discoloration of the toes, or muscle cramping after walking short distances (intermittent claudication). Later findings may include a sore that won't heal (ischemic ulcer), pain at night while resting in bed, or tissue death to part of the foot (gangrene).

    The diagnosis of ischemia is made by reviewing the patient's symptoms, examination of the foot, and special testing to evaluate the circulation. The examination should reveal cold skin temperature, and skin atrophy that causes the skin to appear shiny or paper thin with loss of normal hair on tops of the toes and on the lower leg. There is often a color change associated with ischemic feet. This may show as a purple discoloration of the toes, white blanching of the toes when the foot is elevated, and red discoloration when the foot is hanging down. Additionally the two arterial pulses in the foot will not be as strong as normal, or may be entirely absent. Certainly the presence of a pale looking ulcer, or black gangrenous toes would be an ominous sign of poor circulation.

    When these findings are present further testing is usually required. This will often includearterial Doppler testing. This test uses sound waves to listen to the blood flow through the arteries and is able to record the quality of the blood flow and also the blood pressure. If the quality of blood flow is poor and the pressure is greatly diminished, this would indicate a lack of adequate blood flow. A second test may be required to further determine where the arterial blockage is located and how much blood is able to squeeze past the blockage. This test is known as an arteriogram. The arteriogram requires the injection of a special dye into the artery so that the artery will be visible when an x-ray is taken. This x-ray can then show where the artery is blocked and how much blood can flow past the blockage.

    Treatment

    In the early stages of ischemia of the foot, the doctor will often recommend a program of walking exercises to increase blood flow, protective shoes and insoles if necessary, to protect the skin from rubbing producing irritations which may lead to ulcerations. Medications are also available to help improve the blood flow into the feet.

    In more advanced stages of ischemia, a referral to a vascular specialist is appropriate for further evaluation. Oftentimes, if the patient is in otherwise good general health, a surgery may be recommended to bypass the blocked artery or to clean out the area of blockage. This can be major surgery, however in these cases, failure to improve the circulation into the foot may result in gangrene, which may ultimately require amputation of part of the foot or leg. The surgery is an attempt to save the foot and leg from the impending amputation. The surgery has improved over the years and the chances for success are now greater than ever before. However, each individual needs to be evaluated as to the potential risks and possible benefits from this type of surgery.

  • Tarsal Tunnel Syndrome
    Tarsal Tunnel Syndrome is due to compression of a nerve called the Posterior Tibial Nerve. The nerve passes into the foot from around the inside of the ankle just below the ankle bone. Just beyond this point, the nerve enters the foot by passing between a muscle and a bone in the foot. This area is called the Tarsal Tunnel. The Posterior Tibial Nerve is the largest nerve that enters the foot. At the level of the ankle, the nerve branches out like the branches of a tree as it goes out toward the toes. This nerve supplies most of the sensation to the bottom of the foot and the muscles in the bottom of the foot. When pressure is placed on this nerve, a burning or numbness will be experienced on the bottom of the foot. The area of the bottom of the foot that is affected can be variable. Most commonly, it affects the outside portion of the bottom of the foot. It can also affect the toes, mimicking a neuroma. The most common cause of Tarsal Tunnel Syndrome is a flat foot or a foot in which the arch flattens excessively while walking. This is aggravated by excessive tightness of the clf muscles which restricts ankle joint motion. Over time, this causes the nerve to stretch or become compressed in the area of the tarsal tunnel. The condition is slowly progressive and occurs more commonly after 30 - 40 years of age. Other causes of Tarsal Tunnel Syndrome are the formation of soft tissue masses such as ganglions, fibromas, or lipomas that may occur in the Tarsal Tunnel and cause compression of the nerve. Also, small varicose veins may form around the nerve that can also cause compression of the nerve.

    Flattening of the arch of the foot is due to an abnormal function of a joint complex called the Subtalar Joint. This joint complex is located just below the ankle joint. When this joint allows the foot to flatten excessively, the foot becomes over pronated. Pronation is a normal movement of the foot, but when it occurs too much of the time, it causes several different problems to occur in the foot, one of them being Tarsal Tunnel Syndrome.

    Diagnoses

    Diagnosis of Tarsal Tunnel Syndrome is made by physical exam and the patient's history of their complaint. A history of gradual and progressive burning on the bottom of the foot should alert the doctor to the possible diagnoses. Physical exam will often reveal a flat foot or over-pronation of the foot that is observed when the patient walks. Observation of the area just below the ankle bone on the inside of the ankle may reveal a slight swelling. Tapping with the tips of the fingers or a neurological hammer in this area may reveal a tingling sensation in the bottom of the foot. Quite oftern there is also associated calf muscle tightness. X-rays may be of little value, because they will not show the nerve or reveal any evidence of soft tissue masses. X-rays may be useful in determining the extent of pronation of the foot but only if the x-ray is taken with the patient bearing full weight on the foot. An MRI may reveal the existence of a soft tissue mass, but will not demonstrate any damage to the nerve. Nerve conduction studies will reveal if there is damage to the Posterior Tibial Nerve, but will be negative in the early stages of the condition.

    Other conditions that may cause similar symptoms are diabetic neuropathy, alcoholic neuropathy, or nerve compression at a level higher than the ankle. Poor circulation can also cause burning of the feet. If you experience these symptoms, you should consult your doctor at the earliest possible time.

    Treatment

    Treatment of Tarsal Tunnel Syndrome is directed at correcting the abnormal pronation of the foot. This is accomplished with functional foot orthotics, calf muscle stretching and the use of a dorsal night splint. Orthotics are custom-made inserts for the shoes that correct abnormal function of the foot. Treatment with oral anti-inflammatory medications, vitamin B supplements, or steroids may provide some benefit, but are rarely curative. Calf muscle stretching can be useful, because it eases the tension and strain about the ankle joint. If the Tarsal Tunnel Syndrome is caused by a soft tissue mass, then surgical removal of the mass may be necessary. Surgical correction of Tarsal Tunnel Syndrome in the absence of a soft tissue mass has a very low success rate. This surgery, called nerve decompression, is intended to release the pressure on the nerve by freeing the soft tissue structures about the nerve as it passes through the tarsal tunnel. (See surgical Exploration for Tarsal Tunnel Syndrome) This surgery does not correct the over-pronation of the foot, however, and functional foot orthotics should be worn following the surgery.

    When there has been significant damage to the nerve, permanent nerve damage may be present. In this case, a complete cure is very unlikely, and treatment is directed at easing the symptoms. Certain medications available, by prescription from your doctor, may be beneficial for the burning pain that may be experienced at night. Magnetic insole therapyand Galvanic Nerve Stimulation are alternative forms of treatment that may provide relief. A referral to a pain medicine specialist may also be necessary.

  • Tarsal Coalition

    A tarsal coalition is a bone condition that causes decreased motion or absence of motion in one or more of the joints in the foot. The lack of motion or absence of motion is due to abnormal bone, cartilage or fibrous tissue growth across a joint. When excess bone has grown across a joint there is usually little or no motion in that joint. Cartilage or fibrous tissue growth can restrict motion of the affected joint to varying degrees causing pain in the affected joint or in surrounding joints.

    The decreased motion can cause pain in surrounding joints as they try to compensate for the affected joint. When one joint has restricted motion the surrounding joints will be stressed more than normal. This is an attempt to "take up the slack" for the diseased joint.

    Tarsal coalitions can occur outside of a joint as well. This is referred to as a bar. A bar connects two bones that don't normally touch or have a joint between them. The bar will limit motion in surrounding joints causing abnormal wear and tear to the joints of the foot. This can lead to early arthritis and pain. The bar itself can be painful as well if it is incomplete, traumatized during walking, sporting activities, or an accident.

    In the foot, the bones found at the top of the arch, the heel, and the ankle are referred to as the tarsal bones. Thus, a tarsal coalition is an abnormal connection between two of the tarsal bones in the back of the foot or the arch. This abnormal connection between two bones is most commonly an inherited trait and passed down from generation to generation. All coalitions are not inherited though. They can also arise from outside sources such as arthritis, infections, trauma and abnormal bone growth. These outside causes are much less frequent.

    Symptoms

    Patients with a painful tarsal coalition commonly describe an aching sensation deep in the foot near the ankle or arch. In many cases, muscle spasm on the outside of the affected leg is present. This is a natural reaction of the body as it tries to limit the painful motion occurring in the foot. Patients may notice that the affected foot is not as flexible and appears significantly more flattened when compared to the other foot. This only holds true if only one foot is affected, as it is common for both feet to be affected. All flat-footed people do not have tarsal coalitions. There are many causes of flat feet.

    Symptoms most commonly appear in the teenage or early adult years depending on the location of the coalition. It should be noted that not all tarsal coalitions become symptomatic. The onset of symptoms may be delayed into adulthood.

    Diagnosis

    Diagnosis of a tarsal coalition can usually be made from symptoms described by the patient to the doctor. X-rays are usually taken and in most cases a CT scan or MRI will confirm the diagnosis and provide valuable information regarding the type of coalition, its location, and how the joints have been affected.

    Treatment

    There are a variety of methods to treat a tarsal coalition depending on the severity of the condition, the age of the patient, and which joint is affected. Conservative treatment involves non-surgical treatment options. Conservative treatment is directed toward reducing motion in the affected joints to decrease pain and muscle spasm. Orthotics (shoe inserts) are commonly used accomplish this decrease in motion. Physical therapy and anti-inflammatory medication may be utilized as well. Cortisone injections in the affected area may provide relief for an indefinite period of time. These conservative methods of treatment may or may not provide long-term relief.

    If symptoms do persist surgical correction is often entertained. Surgical intervention will vary depending on the type of coalition, its location, and the amount of arthritis it has caused in the foot. Surgery can involve removing the coalition to allow for more normal motion between the bones. Many times surgery may involve fusing the affected joint or surrounding joints. This is designed to limit or completely stop the painful motion of the affected joints.

    Recovery from surgery often involves a period of non-weight bearing on crutches and utilization of a cast. Physical therapy will often be used once the normal bone healing is complete to restore muscle tone and full available range of motion.(For more information see Hindfoot and Ankle surgery.

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