Diagnostic ultrasound imaging has greatly improved the services and diagnostic options available to our patients. For example, those soft tissue problems that otherwise cannot be seen on x-rays can often be seen with ultrasound imaging. Tendon problems and the plantar fascia itself can be clearly visualized and evaluated. Often this can be done right during office visit rather than setting up a much more costly MRI. Foreign bodies such as glass and metal objects can be identified and mapped out. Soft tissue growths such as a ganglion cyst show up very clearly with ultrasound imaging.

Ultrasound imaging can also be used to facilitate procedures. For example, ultrasound guided injections allow for precise placement of medication. This allows a lower dose of medication to be utilized to help minimize the potential for side effects. For example, heel spur injections and injections for plantar fasciitis with cortisone are much more effective when they are placed directly in the most inflamed portion of the plantar fascia. Another example is ultrasound guided injections for Morton's neuroma. Dehydrated alcohol is utilized for sclerosis of the pathologic nerve tissue. This is done instead of typical neuroma surgery.

Dr. Young and Dr. Nelson utilize ultrasound imaging. These may include evaluation of tendonitis or plantar fasciitis. The extent of damage and local edema or deep tissue swelling can be evaluated, often allowing for diagnosis that otherwise might have required an MRI. Other applications include ultrasound guided injections. Utilizing this technique, they can locate the area that needs treatment and make certain that the injection is precisely placed where it is most beneficial.

 

For example, when a patient needs an injection for heel spur or plantar fasciitis, if the injection were inadvertently placed into the fat pad on the bottom the heel, it could damage the fat pad (causing atrophy). Also it would provide much less relief for the inflamed plantar fascia. Therefore, by having precise placement with ultrasound imaging, a lower and safer dose of the cortisone can be utilized and the doctors can be certain that this is placed exactly where it is needed.

Physical Therapy Available in our Clinic:

• Physical therapy treatments can help compliment the overall treatment plan to resolve swelling and pain. They can also help after surgery to speed tissue healing and reduce swelling. Most physical therapy treatments or modalities, should be done several times a week over the course of several weeks.

Therapeutic Ultrasound:

• The deep tissue sound waves from an ultrasound unit can reduce the underlying inflammation and tissue edema (swelling). This can speed the healing for conditions such as plantar fasciitis and other soft tissue inflammatory conditions and injuries. This can be done in our clinic. When needed, we also refer our patients to outside physical therapy facilities.

Interferential Electrical Stimulation Therapy:

• This type of electrical stimulation can reduce deep tissue swelling or edema and inflammation. It is also thought to help restore damaged and injured tissue's electrical potentials to that of normal tissue. It can be very effective at treating chronic pain conditions.

Home-Based Interferential Electrical Stimulation Therapy:

• We have multiple portable electrical stimulation units that we "check out" to our patients, so they can take them home. E stim is done for at least 20 minutes everyday for period of two or three weeks. The great advantage is, that it can be done in your home every single day instead of two or three times a week. This has a greater therapeutic benefit, but also it has the advantage of not having to drive to a clinic multiple times over the course of several weeks.

PEMT- Pulsed Electronegative Magnetic Therapy:

• This is the technology utilized by many biomedical companies. This treatment is used for fractures or fusion sites that will not heal. These may be described as a delayed or nonunion of a fracture. A classic example is a delayed or nonunion of a Jones fracture of the fifth metatarsal base. The combination of poor blood supply, and constant tension by the peroneal tendon allows for movement at the Jones fracture. So, rather than just cast immobilization, this is often treated with surgical fixation of the fracture site and a bone stimulation unit. However, most commercially available bone stimulation units are very expensive and insurance companies have set up strict protocols to limit excessive use. Dr. Young prescribes these bone stimulation units when needed.

The Actipatch Treatments:

• This is another interesting use of pulsed electronegative magnetic therapy. The Actipatch units are small portable electrical devices. These deliver pulsed electronegative magnetic therapy to a soft tissue area to promote and speed soft tissue healing. An example would be the Actipatch unit designed for plantar fasciitis (heel pain). These can be an excellent part of an overall treatment plan for plantar fasciitis.

Dr. Young & Dr. Nelson utilize electrical stimulation during many procedures. The gel electrode pads are placed behind the area that will be receiving a local anesthetic injection. Our patients increase the electrical stimulation until it becomes quite strong but not painful. It is always in the patients control. Then, while the peripheral nerves are kept stimulated and busy, the doctor is able to inject the local anesthetic with a much more comfortable technique. At our clinic, patients prefer this technique to any other they have experienced before. Our patients are surprised to find that they can have an injection that has little or no pain at all.

We often hear: "If I only would've known this was available, I would have come in much sooner to have my foot treated."

We have x-ray equipment within our clinic that includes the x-ray unit and the automatic x-ray film processor. This allows us to take any ankle and foot x-rays needed. X-ray films are quickly developed by the automatic processor, so they are available if necessary during the same office visit.

What is cortisone?
Cortisone is a type of steroid that is produced naturally by a gland in your body called the adrenal gland.

Injectable cortisone is synthetically produced, but is a close derivative of your body's own product.  The most significant differences are that synthetic cortisone is not injected into the blood stream, but into a particular area of inflammation.  Also, the synthetic cortisone is designed to act more potently and for a longer period of time. 

How does the cortisone injection help?
Cortisone is a powerful anti-inflammatory medication.  By injecting the cortisone into a particular area of inflammation, very high concentrations of the medication can be given while keeping potential side effects to a minimum.  Cortisone injections usually work within a few days and the effects can last up to several weeks or months. 

What are some common reasons for a cortisone injection?
Many conditions where inflammation is an underlying problem are amenable to cortisone shots.  These include, but are certainly not limited to:

• Plantar fasciitis
• Neuromas
• Capsulitis
• Tendonitis

Are there side effects?
Yes, probably the most common side effect is a "cortisone flare," a condition where the injected cortisone crystallizes and can cause a brief period of pain worse than before the shot.  This usually lasts a day or two and is best treated by icing the injected area.  Another common side effect is whitening of the skin where the injection is given.  This is only a concern in people with darker skin and is not harmful, but patients should be aware of this.

Other side effects of cortisone injections, although rare, can include infection.  Because cortisone is a naturally occurring substance, true allergic reactions to the injected substance do not occur.  However, it is possible to be allergic to other aspects of the injection, most commonly the betadine used to sterilize the skin. 

Weakness in the leg muscles, contracture with limitations in the movement in the joints of the legs or feet should be evaluated by your physician immediately.

When a child complains of soreness in the legs it is frequently said that they are having "growing pains". In fact the act of growing is not a painful condition. "Growing pains" indicate that something abnormal is occurring. The muscles in the lower leg control the function of the foot. When the feet are not functioning properly it causes the muscles in the legs to fatigue. This fatigue results in soreness or cramping in the muscles of the legs. This may manifest itself early in development of the child. A newly walking child may prefer to be carried or held instead of exploring their new world. Youngsters may protest walking in the mall or at amusement parks, tiring easily during a fun adventure.

Treatment

Treatment consists of using custom molded inserts for the shoes called orthotics to correct the underlying abnormal foot function. This in turn reduces the stress experienced in the leg muscles and will ease or eliminate the soreness. The results can be quite dramatic with a rapid improvement in the child's symptoms. As with all medical treatments results may vary and orthotics may failure to resolve the problem.

Gout is caused by abnormal metabolism of substances called purines that result in the accumulation of uric acid in the blood stream. Purines are a by-product of cell break down. When the excretion of the uric acid is hampered the accumulated uric acid in the blood stream causes crystalline deposits to form in joints or in the soft tissues. When this happens, there is a sudden onset of extreme pain with associated swelling, redness, and increased warmth to the skin or joint. Classic gout occurs in the big toe joint. It also commonly occurs in the knee joint. Rarely is it seen in more than one joint at a time. Uric acid accumulation in other joints and areas of soft tissue is less common. When gout presents in these areas it, may not be recognized as gout by the treating doctor.

Gout can also mimic an infection. Your doctor will evaluate you for the possability of infection and may treat you for infection as well as gout.

Diagnosis

As the crystalline deposits form in the joints and soft tissue, the uric acid levels in the blood stream can return to normal. Blood tests taken during an attack of gout may demonstrate a normal uric acid level. This can make diagnosis more difficult, and the physician must rely on his or her clinical experience to make the diagnosis. Other areas that gout may present itself are the tops of the foot, the heel and the ankle joint. In the chronic form of the disease, called tophaceous gout, the repeated deposition of uric acid will from nodules about the joints and tendons. These nodules can spontaneously open and drain a chalky like substance. An attack of gout can resemble an infection. An elevated temperature may also be present. This is worrisome to the physician because an infection in a joint can be a very damaging event. Some doctors may wish to take a sample from the joint so that it can be analyzed for gout and cultured for bacteria.

Treatment

Treatment often consists of both medications for gout and for infection. Immobilization of the foot with a removable cast or the use of crutches is useful. Once the proper medication is prescribed the symptoms of gout will start to subside quite rapidly. Left untreated the clinical course may take several days for the gout attack to subside.

Factors that contribute to the onset of gout are alcohol, red meats, asprin and certain medications for high blood pressure. Gout occurs most frequently in men. Women will not get gout until after menopause unless they have had a hysterectomy. Patients with long standing diabetes who may have kidney damage due to their disease, and patients who have kidney disease from other causes can develop gout. These patients may exhibit atypical forms of gout. In these instances, more than one area may be affected; the tops of both feet, for example, may develop gout.(Interossiuos gout)

Typically the onset of gout is sudden and intense. Frequently, the patient will go to bed feeling fine and wake up the next morning in execrating pain. The attacks can become recurrent, and over time cause permanent damage to the affected joint (arthritis). Recurrent gout should be treated with medication to reduce the blood uric acid levels. The most common medication used is Allopurinol. This medication should not be started during an acute attack. If this medication is given during an acute attack it will make the condition worse. Acute attacks of gout are treated with a variety of prescription anti-inflammatory drugs.

Raynaud's Disease is a vasospastic disorder most commonly affecting the hands and feet. A vasospasm occurs when the smooth muscles controlling the small arteries supplying circulation into the hands and feet contract. This smooth muscle contraction, or spasm, makes the arteries so small that blood has difficulty passing through. The most common event causing the vasospasm is exposure to cold temperature. Raynaud's disease must be differentiated from Raynaud's phenomenon. Raynaud's disease is a disease that is not associated with any other specific disease entity. Raynaud's phenomenon has the same findings, as Raynaud's disease except there is an underlying disease associated with the vasospasm. Raynaud's phenomenon may be seen with rheumatoid arthritis, scleroderma, lupus, and other diseases. The condition is aggravated by smoking. A single cigarette may decrease the circulation by one half for more than an hour. Raynaud's disease is most common in young women, and has no known cause. It typically is found in both feet and both hands. It appears that the threshold for vasospasm is lowered in these individuals, and may occur following exposure to cold, or during times of stress.

Diagnosis

The diagnosis of Raynaud's disease is a clinical diagnosis based upon the patients' symptoms and the findings on examination. Patients with Raynaud's disease will often hear the expression, ""Cold hands, warm heart"" when shaking hands with others. This is because the arterial vasospasm decreases blood flow into the hands and feet. In addition to the cold skin temperature, there is a pattern of color changes seen in the fingers and toes. Initially after exposure to cold, the toes and fingers will turn white, then as the oxygen is depleted they become cyanotic which is a blue color, finally the spasm relaxes and there is an excess of blood flow which turns the toes red and warm (reactive hyperemia). This pattern of triphasic color change, white to blue to red, is a hallmark of Raynaud's disease. However, not all individuals will have the triphasic (three-color) change. Some will have a biphasic (two color) change going directly from white to red.

The length of vasospasm may last from several minutes to several hours. This may be accompanied by pain, or more commonly by numbness. In severe cases there may damage to the skin on the tips of the toes and fingers with an appearance similar to frostbite. These areas may develop into ulcers (sores) which can be very painful.

Treatment

In mild forms of Raynaud's disease the simplest treatment is to protect the hands, and feet from cold exposure. Since cold is the cause of the vasospasm, preventing exposure to cold will prevent the spasm from occurring. This may require insulated boots and thick warm socks in colder climates. Dressing in layers, with new polyester liners and new insulating materials may be helpful. Most sporting goods stores that stock hiking or camping equipment will be able to help in this regard. Cigarette smoking contains nicotine, which is known to cause vasospasm. Discontinuation of cigarette smoking will be a definite benefit for the individual with Raynaud's disease. In more severe cases, or in those with recurrent episodes, medications are available to help relax the arterial smooth muscle. Medications that have been used successfully in some individuals include phenoxybenzamine, prazosin, nifidipine, pentoxyphylline, and guanethidine. These medications are only available by prescription, and patients must be monitored for potential side effects.

Circulation disorders includes a large number of different problems with one thing in common, they result in poor blood flow. Specifically, the term peripheral vascular disease refers to blood flow impairment into the feet and legs (although it could include the arms and hands as well).

Blood is circulated throughout the human body by the strong, muscular pump called the heart. With each heartbeat, blood is pushed along through blood vessels called arteries that carry the oxygen and nutrient rich blood to all parts of the body including the legs and the feet. The individual cells in the body take up the oxygen and nutrients. Then a second set of blood vessels known as veins carry the oxygen depleted blood back to the heart and lungs to get more oxygen, and again be pumped throughout the body. Peripheral vascular disease may refer to arterial inflow disorders, (arterial insufficiency) or venous outflow disorders (venous insufficiency).

Arterial Insufficiency

Arterial inflow disorders are categorized by the size of the artery involved. If a large artery in the thigh or behind the knee becomes blocked by cholesterol deposits this is referred to as large vessel disease or atherosclerosis. The result may be a painful ischemic foot, which means there is a severe lack of arterial blood flow from the heart into the foot. If smaller arteries like those in the lower leg or foot is blocked, this is referred to as small vessel disease, or arteriosclerosis. This too can result in ischemia of the foot. Small vessel disease is seen more often in diabetics, but can affect non-diabetics as well. If the skin of the feet or legs lacks adequate blood flow a sore will develop which may be difficult to heal. These sores are known as ischemic ulcers. Any blockage to arterial inflow will result in a circulation problem to the body tissues down stream. Occasionally a small blockage will occur in the small arteries that supply blood to a toe. This is known as a "Blue Toe Syndrome." Another arterial inflow problem may result when the smooth muscles that control the size of the arteries go into spasm. The arterial muscle spasm can block the blood from circulating into the foot. One common vasospastic disorder is called Raynaud's Syndrome. A second vasospastic disorder is called acrocyanosis.

Venous Insufficiency

Venous outflow disorders refer to problems getting blood from the foot back to the heart. There are two sets of veins in the feet and legs to help bring the blood back toward the heart. The superficial venous network refers to veins located just beneath the skin. The deep venous networks are veins located closer to the bones and are not visible when looking at the foot or legs.

Varicose veins refer to an enlargement of the veins and a loss in the ability of the vein to properly maintain blood flow back toward the heart. When this occurs blood can collect in the feet and legs. Superficial varicose veins may appear as unsightly cords or a small bunch of grapes, which usually appear on the tops of the feet, around the ankles and may extend upward to the knees and thighs. Deep varicose veins while usually not visible will result in chronic swelling of the feet, ankles and legs. When the blood is not circulated from the feet back to the heart gravity will cause the fluid to collect in the feet and ankles. This results in swelling, called edema. Chronic edema over a long period of time may cause a discoloration of the skin around the ankles. The skin can become inflamed, and is know as venous stasis dermatitis. If left untreated the skin will become weakened and a weeping sore will develop, usually on the inside of the ankle called a venous stasis ulcer.

A potentially serious consequence of blood collecting in the feet and legs is the formation of blood clots in the veins. A superficial vein blood clot will result in a painful, inflamed superficial vein called superficial phlebitis. When a blood clot forms in a deep vein, it is called deep venous thrombosis, or deep phlebitis. This is a serious condition that causes painful swelling of the leg and may result in part of the clot breaking free. If the clot should travel back up to the heart and get caught in the lungs, it is referred to as a pulmonary embolus which can be life threatening and requires emergency treatment.

There are several causes of pain on the top of the foot. The type of pain and its location help the doctor in determining the cause of the pain and helps to direct them in the best treatment for the patient

Pain of sudden onset without the occurrence of injury on the top of the foot just behind the toes may be a stress fracture of a metatarsal bone. There is frequently swelling in the area and it is painful to the touch.

Another common area of pain occurs near the middle of the top of the foot, generally a bit to the outside of the foot. In this area of the foot the tendons that go to the toes can become inflamed. This is called extensor tendonitis. One cause of this condition is excessive tightness of the calf muscle. When the calf muscle is tight it places excessive stress on the tendons on the top of the foot that pull the foot upward and against the tightness of the calf muscles. Wearing a shoe with a one-inch heel will help to take the stress off of the tendons on the top of the foot. Aggressive stretching of the calf muscle is also very helpful. Oral anti-inflammatory medications can help. When these measures do not work a functional orthotic should be tried. The orthotic corrects the alignment of the foot taking the stress off of the tendons on the top of the foot.

More generalized pain on the top of the foot with swelling or a "thickness" to the foot may be caused by degenerative arthritis. This is seen in people with flatfeet or a slowly collapsing arch.

Another area of degenerative arthritis that causes pain on the top of the foot is in the area of the big toe joint. Jamming of the joint will cause bone spurring to occur on the top of the foot. Pressure from the shoe can cause pain. Treatment for these conditions consists of taking oral anti-inflammatory medications and functional foot orthotics. Surgery can be an option for the degenerative arthritis about the big toe joint. (See hallux limitus)

Generalized pain in the top of the foot that occurs in children and young adults may be due to a condition called Tarsal Coalition. This pain tends to occur on the outside portion of the top of the foot. A tarsal coalition is the abnormal fusion of two or more bones in the rear portion of the foot. It can be hereditary. It tends to get worse with activity. If not treated in its early stages it can cause significant arthritis in the foot causing a limitation in the person's activity. Early diagnosis is made using x-rays and a MRI or CT scan. Treatment is with the use of functional orthotics and on occasion surgery. Early diagnosis and treatment is very important.

Pain can also occur on the top and inside of the foot. In people who are very active in sporting activities can develop pain in this area. The pain can be due to a stress fracture of one of the bones (Navicular bone) in this area. Diagnosis can sometimes be difficult. X-rays are generally negative and if a stress fracture is present the diagnosis may require abone scan or MRI. Treatment consists of rest with a limitation of activity, oral anti-inflammatory medications, below the knee walking casts, functional orthotics or rarely surgical exploration of the area.

Yet another area of pain on the top of the foot is just below the ankle joint on the outside portion of the top of the foot. In this area of the foot there is a small fleshy area. This fleshy area is a small muscle called the Extensor Digatorum Brevis. Underneath the muscle there is a small canal between two bones. This area is called the Sinus Tarsi. In this area there are three small ligaments that can become inflamed. A common cause of this pain is due to a flattening of the foot, which pinches these small ligaments. Sometimes there is actual jamming of two bones causing the pain. Treatment consists of stretching the calf muscles to reduce it effect of flattening the foot, oral anti-inflammatory medication, cortisone injections, functional orthotics and occasionally surgical exploration.