General

  • Erythromelalgia
    Erythromelalgia is a fairly rare disorder manifested by vasodilatation of the blood vessels in the feet. Normally blood flow through the feet and hands is regulated by nerves and muscles in the walls of the blood vessels that either tighten and shrink the vessel's diameter so as to restrict flow or to open the blood vessels diameter to allow for more flow. This is all controlled automatically by the body and is necessary to preserve or give up body heat so that we maintain a constant body temperature.

    For instance, when we are subjected to cold temperatures the blood vessels will constrict and shunt blood back to the heart and body cavity. This is an example of how our body responds to cold and is a survival mechanism to keep us alive if we where exposed to prolonged or severely cold temperatures. The heat of the blood is not allowed to escape in the fingers and toes into the air or water around us and is sent back to the heart to keep the core body temperature warm so your heart will continue to beat. Certainly you have heard "Cold hands, warm heart". When we are hot just the opposite happens and the blood vessels enlarge or dilate allowing for more blood to go to the fingers and toes thereby 'giving up heat' to the surrounding air. The 'cooler blood then goes back to the heart where it helps lower core temperature.

    The vasoconstriction (tightening of the blood vessels) and the vasodilatation (opening of the blood vessels) is always changing and adjusting to maintain blood pressure, control body heat, regulate heart rate, among other functions you don't even think about. Part of the controls for this are partially understood and maintained by the primitive part of our nervous system called the autonomic nervous system. It is this part of our nervous system that is responsible for out heart to beat and for us to breath regularly without having to think about it.

    When these controls fail to operate normally we see the pathologic disease patterns of erythromelalgia or Raynauds disease or phenomenon.Raynauds disease or phenomenon is a vasoconstriction of the blood vessels in the feet and hands. We notice it when our fingers and toes get icy cold and turn blue or even white. This can be a very painful condition depending on how long we are subjected to the cold and the vasoconstriction since the tissues of the hands or feet are deprived of blood and therefore oxygen. In many individuals it may be very mild and not be a problem. All of us experience vasoconstriction to some degree when we are in cold weather. In the disease state however the vasoconstriction does not entirely reverse when subjected to warmer temperatures and a chronic painful situation ensues.

    Erythromelalgia on the other hand is just the opposite. The blood vessels are open or dilated and the oxygen and heat of the blood is discharged into the tissues making them turn red and feel hot all the time. Likewise this can be a very painful condition. It is a more rare disorder and less understood than Raynauds.

    Diagnosis

    Before treatment, the diagnosis should be confirmed. This can be accomplished by a variety of different medical specialties. Internal medicine or an internist is a good place to start to make sure there are no disease factors or other medications causing the Raynauds or erythromelalgia. In many instances the internist will treat the disorder so he may help you monitor medications that have undeliverable side effects or react with other medications.

    Treatment

    These disease states can be treated with varying degrees of success using drugs that induce vasodilatation or vasoconstriction. Unfortunately, the side effects of vasodilators or vasoconstrictors are often times worse than the disease. Obviously, avoiding temperatures or situations that can trigger the responses are also useful. For instance, people with vasoconstrictive problems should wear socks and well insulated shoes to maintain heat. Patients with vasodilatation problems may be more comfortable in sandals, going barefoot, or certainly using a light shoe that can 'breath' to allow heat to escape. In severe conditions pain medications can be a useful adjunct. Hypnosis and biofeedback may have some degree of success in certain individuals if administered by appropriately trained individuals.

  • Electromyography (EMG) / Nerve Conduction Velocity (NCV)

    This test is used to test the nerves and muscles in your entire lower extremity. Your doctor will usually order this test when he suspects that there may be some type of problem with the nerve supply to your foot and leg. Commonly the EMG/NCV test is used to diagnosis one of the following: Tarsal Tunnel Syndrome, Peripheral Neuropathy, Neuromuscular disorders, Nerve palsy or Paralysis, and Radioculopathy. Your doctor typically will refer you to either a hospital or a neurologist to have the test performed.

    The EMG portion of the test is used to record the electrical activity in your muscles. It can diagnose diseases of the nerves and muscles. It can detect conditions such as tarsal tunnel syndrome, inflamed muscles and pinched nerves. A tiny needle, called an electrode, is inserted directly into a specific muscle belly. The electrode then records the activity during the insertion, while the muscle is at rest, and while the muscle contracts. Nerve and muscle diseases alter the pattern of electrical activity in these muscles, which is record both audibly and on a computer screen. After the first muscle is tested, the electrode may be inserted into another muscle. Muscles chosen for the testing vary with the patient's symptoms and may be modified, depending on the results from the first muscles tested. Total testing time may range from just a few minutes to more than an hour, depending upon how many muscles are tested. After the exam, you may feel tenderness in the tested muscles. There is a slight risk of minor, localized inflammation in muscles during the test. This usually lasts only a few hours. Other common patient complaints are pain with insertion of the electrode.

    Most of the time the Nerve Conduction Velocity Test will accompany the EMG Test. The NCV evaluates the health of the peripheral nerve by recording how fast an electrical impulse travels through it. A peripheral nerve transmits information between the spinal cord and the muscles. You will be resting on a cart or bed and electrodes will be taped to your skin. A stimulator will be held against your skin, which sends out a small electrical charge along the nerve. You may feel a tingle or your muscles may twitch but this shock is not harmful. Each test will take only a few minutes. After the exam the electrodes will be removed and your skin cleaned. The time between the stimulation and response will be recorded to determine how quickly and thoroughly that the impulse is sent. A number of nervous system diseases may reduce the speed of this impulse. Each nerve test takes just a few minutes to an hour, depending upon how many nerves are being tested.

    While the hospital or neurologist's office will give you instructions for the day of the examination, a few general preparations will help. Eat normally and take medication as you usually would. If you are taking a blood thinner, make sure you inform the testing facility and ask the ordering physician about the use of the medication and the timing of the test. Bath or shower the morning of the examination. Avoid bath oils or any skin lotions or emollients the day of the examination.

    A typical EMG/NCV of the lower extremity takes approximately 45 minutes. This test is an important tool for diagnosing diseases of the nervous system, you can help ensure the best results if you relax and cooperate with the technicians. Make sure that you ask any questions that you have about the test before it is performed. 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.

  • Diabetic Neuropathy

    Diabetic Peripheral Neuropathy

    People with diabetes have an abnormal elevation of their blood sugar, and lack adequate insulin to metabolize the blood sugar. As a consequence, the blood glucose (sugar) abnormally enters certain nerve tissue and damages the nerve. This can occur in any type of diabetes. It does not matter if the patient is on insulin, is taking pills, or is diet controlled. The nerve damage that occurs is considered to be permanent.

    As the nerve damage occurs, the protective sensations are affected. These include a person's ability to determine the difference between sharp and dull, hot and cold, pressure differences, and vibration. These senses become dulled and/or altered. The process begins as a burning sensation in the toes and progresses up the foot in a "stocking distribution". As the condition progresses, the feet become more and more numb. Some people will feel as though a pair of socks on their feet, when in fact they do not. Other patients will describe the feeling of walking on cotton, or a water-filled cushion. Some patients complain of their feet burn at night, making it difficult to sleep. The feet may also feel like they are cold, however, to the touch, they have normal skin temperature. Diabetic peripheral neuropathy is not reversible. The progression of the condition can be slowed or halted by maintaining normal blood glucose levels.

    As the patient develops diabetic neuropathy, they have a greater risk of developing skin ulcerations and infections. Areas of corns and calluses on the feet represent areas of excessive friction or pressure. These areas, if not properly cared for by a foot specialist, will often break down and cause ulcerations. Ulcerations and infection can form under the callused area. These callused areas may not be painful. As a result, they can progress to ulceration without being noticed. Ingrown toenails can progress to severe infections in people with neuropathy. Simple things like trimming the toenails present a risk to these patients because they may accidentally cut the skin and not feel it. People with neuropathy must be very cautious and inspect their feet daily. They should not soak their feet in hot water or use heating pads to warm their feet. This can result in accidental burns to the skin. Barefoot walking should be avoided because of the risk of stepping on something sharp and not being aware of it. The inside of the shoes should be inspected before putting the shoes on to insure that no foreign object is inside the shoe ( see Do's and Don'ts-Diabetic Foot Care Tips).

    Alcoholic Peripheral Neuropathy

    Alcoholic neuropathy is caused by the prolonged use of alcoholic beverages. Ethanol, the alcoholic component of these beverages, is toxic to nerve tissue. Over time, the nerves in the feet and hands can become damaged resulting in the same loss of sensation as that seen in diabetic neuropathy. The damage to these nerves is permanent. A person with this condition is at the same risk, and should take the same precautions as people with diabetic peripheral neuropathy. Peripheral neuropathy can also be caused by exposure to toxins such as pesticides and heavy metals.

    Treatment For Peripheral Neuropathy

    Treatment for peripheral neuropathy is, for the most part, directed at the symptoms of the condition. Vitamin B12 injections may be helpful if the patient has a vitamin B deficiency. There are certain oral medications that may ease the burning pain that can be prescribed by your doctor. Topical ointments should only be used with the advice of your doctor. Magnetic therapy and Galvanic Stimulation are alternative forms of treatment but results are varied and difficult to quantify.

  • Design In Running, Court, And Fitness Shoes

    As recently as thirty-five years ago, athletic shoes consisted of just a few shoes that were used for a wide variety of athletic events. There were a few tennis and basketball shoes. There were no shoes marketed specifically as walking shoes. Aerobics or fitness shoes were nonexistent. Running shoes only amounted to a few in number.

    However, in today's athletic shoe stores, the number of brands and styles of shoes for all types of sports is staggering. There are shoes made specifically for wrestling, rock climbing and windsurfing in addition to the more common sports such as running, basketball, tennis, racquetball, aerobic dance and walking. In the running shoe market alone, there are nine major shoe manufacturers with each manufacturer having about five to ten running shoe models within their line. Even though the increased selection of shoes increases the possibility of finding just the right shoe for each set of feet, the large selection of models creates a large degree of confusion among the consumer.

    It is actually this diversity and complexity within athletic shoes that is their most interesting aspect. Shoes that have different shapes, are made of different materials, and which are put together by different construction methods all will function on the foot differently. The purpose of this article is to explain the major structural differences between the three broadest categories of athletic shoes (i.e. running shoes, court shoes and fitness shoes) so that their functional differences may be better appreciated.

    Running Shoes

    Running, like walking, is considered a straight ahead sport since it involves no sudden stops, turns or other maneuvers. Most runners land on their heels and then propel off of their toes. This heel to toe cycle is repeated hundreds and thousands of times every running session. The major biomechanical differences between running and walking are that in running there is always one point during running when both feet are off the ground and also during running the impact forces which the foot absorbs are at least twice as great as that found in walking.

    Most runners strike on the outside of the heel, rapidly pronate, stay pronated for a brief instant and then resupinate as the heel leaves the ground during the push-off phase of running. [Pronation of the foot is a rolling inward of the ankle in which the arch flattens. Supination of the foot is a rolling outward of the ankle in which the arch increases in height.] Due to the large degree of variation within the population, there are a large number of runners who pronate excessively during running causing a multitude of running injuries such as posterior tibial tendinitis, plantar fasciitis and pes anserinus bursitis, to name a few.

    Because of the increased impact forces and increased excessive pronation seen in running, running shoes must be designed both to help reduce excessive shock to the body and also help reduce pronation in the foot (Fig. 1). Unfortunately, the same shoe design characteristics that are best at helping to control pronation also tend to lessen the ability of the shoe to cushion the foot. And conversely, any shoe designed to maximize the cushioning of the foot during running will tend to have decreased ability in helping to control pronation.

    To better understand how the characteristics of running shoe design affect foot function it is important to detail the structural components of the running shoe. Every shoe is made of two basic parts, the sole and the upper. The sole protects the foot from the ground and provides a layer of cushion for the foot. The upper covers the top and sides of the foot to provide a comfortable fit between the foot and the shoe and to improve stability of the foot on the shoe sole.

    In the running shoe, the sole is made up of two distinct layers, the outersole and the midsole. The outersole is the part of the sole that contacts the ground. It is made of a thin layer of relatively hard, abrasion resistant material which functions to resist wear, provide traction and allow flexibility in the forefoot for propulsion.

    Many running shoes use a rubber compound with a high carbon content in the heel and forefoot area, which is similar in composition to an automobile tire, so that the outersole will resist the abrasion that comes from the heel striking the ground. Running shoe outersoles also are constructed with studs or ridges in the midfoot and forefoot area to aid traction on soft or slippery surfaces, such as wet grass or slick pavement. In addition, most running shoe outersoles also incorporate some form of transverse grooves placed in the area of the forefoot so that the shoe will be more flexible in the forefoot once the heel leaves the ground during the push-off phase.

    The midsole, however, is the part of the running shoe that either makes it work well or makes it work poorly. The midsole is sandwiched between the upper and the outersole. The upper is glued or bonded to the top surface of the midsole. The midsole is the most important part of the running shoe because its design and construction largely determine whether the running shoe will be a shoe which is good at providing cushioning, good at controlling pronation, good for heavy runners or good for nothing.

    Running shoe midsoles are designed so that there is thick cushioning under both the heel and forefoot to help provide cushioning to the heel and forefoot. The total height of the midsole and outersole under the heel is generally about 1 inch and the total height of the midsole and outersole under the forefoot is about 5/8"". The 3/8"" difference of sole thickness between the heel and forefoot in many running shoes tends to be preferred by most runners and also reduces the strain on the Achilles tendon, therefore, reducing the likelihood of Achilles tendinitis.

    The midsole may be constructed of various materials to provide cushioning and pronation control. The two most common materials used in the construction of running shoe midsoles is ethyl vinyl acetate (EVA) or polyurethane (PU). EVA is a copolymer of ethylene and vinyl acetate that has microscopic air bubbles within it that makes it lightweight and very cushiony. PU also has a microscopic air bubble structure like EVA but is generally firmer and more resistant to compression than EVA.

    Running shoe manufacturers use combinations of different densities of EVA and/or PU within the midsole of the shoe, along with gel packets, air bags, plastic plates and other exotic materials to provide what they believe is the proper amount of cushioning and pronation control for the shoe. Many running shoe midsoles have a firmer midsole material or a hard plate under the medial heel and a softer midsole material under the lateral heel so that the medial heel resists compression more than the lateral heel when the heel strikes the ground in running [Medial is toward the big toe, lateral is toward the little toe]. This ""dynamic varus wedge"" effect does effectively help control foot pronation to some extent. The softest midsole material is generally placed under the forefoot since most runners find that good forefoot cushioning is a very desirable feature when running on hard surfaces.

    The upper of the running shoe is usually made of a combination of lightweight nylon and thin synthetic or natural leather to reduce the total weight of the shoe. Since running involves at least a thousand footstrikes per mile, a lightweight running shoe is critical to insure that the runner can move at a faster pace with less fatigue. One drawback to the lightweight materials used in running shoe uppers is that they all tend to suffer in side to side stability since the thin material in the upper is ineffective at resisting medial and lateral shifting of the foot on top of the sole of the shoe.

    The upper of a running shoe also incorporates a stiff heel counter that is commonly stiffer than in other athletic shoes to help control excessive pronation or supination during running. Most running shoes also incorporate a raised padded ""Achilles tendon protector"" within the design of their upper to supposedly help protect the Achilles tendon. Most runners find that the ""Achilles tendon protector"" serves only as a convenient handle by which to pull their running shoes on with and serves little importance in protecting the Achilles tendon from injury.

    Within the interior of today's running shoes are removable insoles known as sockliners. Sockliners serve to cushion the foot and provide some arch support. Many sockliners in more expensive running shoes serve to support the arch of the foot more effectively than those seen in cheaper shoes. Nearly all sockliners can be removed easily from the shoes so that custom foot orthoses may be added to the shoe to replace the sockliner if needed.

    One more important fact about running shoe design is that running shoes make excellent walking shoes. Since running and walking are both straight-ahead activities, their basic shoe designs are quite similar. In fact, I recommend running shoes for my patients who walk for exercise in favor of many walking shoes since running shoes are lighter, more comfortable and biomechanically more efficient at helping control excessive foot pronation than the majority of walking shoes.

    Court Shoes

    Court sports include tennis, racquetball, basketball, squash, badminton and volleyball. Because court sports require sudden starts, stops and side to side motions, the best shoe construction for court sports is much different than that required for running (Fig. 2). The sudden side-to-side movements seen in court sports tend to make the foot slide forcefully either in a medial or lateral direction on the shoe sole. For example, if a tennis player is moving quickly toward the right and then uses the right foot to come to a complete stop, the foot will tend to slide laterally on top of the shoe sole. The only thing preventing the foot from sliding directly laterally off of the shoe sole is the upper of that shoe. It is because of this necessity for side-to-side stability that court shoes must be constructed much differently than running shoes.

    Like running shoes, court shoes come in all shapes and sizes depending not only on the sport which the shoe is designed for but also on the manufacturer. Unlike running shoes in which the upper of the shoe always ends just below the ankle bones (i.e. a low-cut shoe), the upper of court shoes may extend partially over the ankle bones to about the ankle joint level (i.e. a mid-cut shoe) or may extend above the ankle bones completely covering them (i.e. a high-cut or high-top shoe). Many basketball shoes tend to be made of a higher cut than other court shoes due to the relatively great frequency of ankle sprains seen with basketball. All other shoe design parameters being equal, the higher the cut of the upper of the shoe, the better that shoe will be at preventing ankle instability during the activity and the heavier that shoe will be.

    Since the goal in a well designed court shoe is to make the upper hold the foot on top of the sole, the uppers of court shoes are thicker and made of heavier weight materials than running shoes or fitness shoes. The uppers of court shoes are constructed of thicker leathers or synthetic leathers than either running or fitness shoes. Lightweight and thin materials such as nylon are used less frequently in court shoe uppers. In addition, many tennis shoes may have an extra layer of synthetic or natural leather toe box reinforcement to prevent the upper from wearing through in the toe box area from the scuffing which occurs during tennis serves.

    Many court shoes also are constructed with an extended outersole or midsole which rises up on the sides to the bottom edge of the upper to give added strength to the sole/upper interface. As a result of the use of thicker upper materials and the side reinforcement of the sole up onto the upper, court shoes are nearly always heavier than the same size of running shoe.

    The outersole of court shoes are usually made of a non-marking rubber compound for traction on outdoor or indoor courts. Court shoes have a much lower profile of tread patterns on their outersoles than running shoes since court sports are nearly always played on a dry, flat and smooth surface. In addition, court shoes often have a circular designs constructed into the outersole under the forefoot area of the sole to act as a ""pivot point"" for the shoe during rotational motions of the foot on the playing surface.

    Like running shoes, court shoe midsoles are predominantly made of either EVA or PU. However, the midsoles of court shoes are firmer and thinner than running shoes to reduce the instability of the court shoe during side-to-side movements. Shoes with firmer soles have better side-to-side stability since the force of body weight through the foot will not deform a firm sole as much compared to a cushiony sole. The more that a shoe sole deforms under the forces which the foot exert on it during aggressive maneuvers, the more likely the shoe sole will tilt to one side or the other which may lead to either pronation or supination instability at the ankle joint complex.

    Thicker soles increase the height of the foot and ankle from the ground that, in turn, increases the distance of the ankle joint complex from the ground. The higher that the ankle joint complex is from the ground, the longer is the lever arm for the reaction force from the ground to cause a either a pronation or supination force on the foot and ankle. Therefore, the thinner soles of court shoes decrease the likelihood of ankle sprains since the ground has a much shorter lever arm to produce pronation or supination forces on the ankle joint complex.

    Fitness Shoes

    About fifteen to twenty years ago there was a dramatic increase in the popularity of aerobic dance. At that time, the shoes worn for aerobic dance were either running or court shoes. Unfortunately, since running and court shoes were not specifically designed for the demands of aerobic dance, many injuries occurred. Those aerobic dancers wearing running shoes had good cushion to the forefoot, but suffered from ankle sprains due to the lack of lateral stability in running shoes. Those dancers wearing court shoes had good side-to-side stability, but suffered from painful symptoms in the forefoot due to the lack of cushioning in the forefoot in court shoes.

    Shoe manufacturers responded with the aerobics shoe that blended technologies from both the running shoe and court shoe. The result was a shoe with a midsole thickness and degree of cushioning midway between that of court shoes and running shoes. In addition, the aerobics shoe had an upper that was midway between the court and running shoe in material weight and thickness.

    Today, shoes made for aerobic dance are very similar in design to those shoes made for the various activities available in a health or fitness club. Therefore, shoes made for aerobic dance and cross-training are now known as "fitness shoes". Understanding the construction of fitness shoes is important since they not only are a very popular style of shoe, but their relatively recent birth into the shoe marketplace demonstrates the ability of shoe manufacturers to design a totally new and unique style of shoe to meet the biomechanical demands of a new sport (Fig. 3).

    The fitness shoe has been designed using technological features from both running shoes and court shoes to create a shoe that is actually a better all-purpose shoe than either the court shoe or the running shoe. It is lighter in weight and more well cushioned than the court shoe and much more able to resist side to side movements of the foot than a running shoe.

    The upper of fitness shoes can range from a low-cut to a high-cut with the most popular height being a mid-cut. The mid-cut upper is a very popular style in fitness shoes since it does provide extra lateral stability without adding a great deal of extra weight to the shoe. The fitness shoe upper is made from a combination of thinner natural or synthetic leather and nylon that decreases the weight of the shoe compared to a court shoe. However, since the fitness shoe upper is more substantial than the upper found in running shoes, the lateral stability of the fitness shoe is greater than in the running shoe.

    Like court shoes, many fitness shoes use an extended outersole or midsole on the medial and lateral sides of the upper to provide extra bonding strength to the sole/upper junction. The extended midsole is now very popular in fitness shoes and does provide an extra degree of lateral stability to the shoe.

    The outersole of fitness shoes are very similar to court shoes being made from non-marking rubber compounds in a low profile. However, the midsole in a fitness shoe is thicker than that seen in the court shoe to provide extra cushioning to the forefoot and rearfoot during aerobic dance, running and other impact activities. Even though the midsole in a fitness shoe is not as thick as that in running shoes, the fitness shoe can safely have a thicker midsole in its design since the side to side activities seen in fitness shoes are not as aggressive as that seen in court sports.

    Conclusion

    Certainly in the case of all the shoes described, it is clear that the structure of the shoe determines how the shoe will affect the function of the foot within that shoe. Whether it is the composition of the outersole, midsole or upper, or it is how the sole is attached to the upper, or it is any other shoe design parameter, the construction of athletic shoes must match the biomechanical requirements of the specific athletic activity in order for the shoe to be useful and desirable for the athlete.

  • Deep Vein Thrombosis

    What is Deep Vein Thrombosis?
    The blood supply of the leg is transported by arteries and veins. The arteries carry blood from the heart to the limbs; veins carry blood back to the heart. The leg contains superficial veins, which are close to the surface, and deep veins, which lie much deeper in the leg. Deep vein thrombosis (DVT) is a condition in which a blood clot (a blockage) forms in a deep vein. While these clots most commonly occur in the veins of the leg (the calf or thigh), they can also develop in other parts of the body. 

    DVT can be very dangerous and is considered a medical emergency. If the clot (also known as a thrombus) breaks loose and travels through the bloodstream, it can lodge in the lung. This blockage in the lung, called a pulmonary embolism, can make it difficult to breathe and may even cause death. Blood clots in the thigh are more likely to cause a pulmonary embolism than those in the calf.

    Risk Factors for DVT:

    Blood or vein conditions: 

    • Previous DVT
    • Varicose veins
    • Blood clotting disorders
    • Family history of DVT or blood-clotting disorders

    Other medical conditions:

    • Heart disease
    • Chronic swelling of the legs
    • Obesity
    • Inflammatory bowel disease
    • Cancer
    • Dehydration
    • Sepsis

    Women's Health issues:

    • Hormone replacement therapy
    • Birth control pills containing estrogen
    • Pregnancy or recent childbirth

    Other:

    • Age over 40 years old
    • Immobility (through inactivity or from wearing a cast)
    • Recent surgery
    • Trauma (an injury)
    • Smoking

    Causes of DVT  
    Many factors can contribute to the formation of a DVT. The more risk factors a person has, the greater their risk of having a DVT. However, even people without these risk factors can form a DVT.

    Signs and Symptoms of DVT in the Leg
    Some people with DVT in the leg have either no warning signs at all or very vague symptoms. If any of the following warning signs or symptoms are present, it is important to see a doctor for evaluation:

    • Swelling in the leg
    • Pain in the calf or thigh
    • Warmth and redness of the leg

    Diagnosis
    DVT can be difficult to diagnose, especially if the patient has no symptoms. Diagnosis is also challenging because of the similarities between symptoms of DVT and those of other conditions such as a pulled muscle, an infection, a clot in a superficial vein (thrombophlebitis), a fracture, and arthritis.

    If DVT is suspected, the doctor will immediately send the patient to a vascular laboratory or a hospital for testing, which may include a blood test, Doppler ultrasound, venogram, MRI, or angiogram.

    Treatment of DVT
    If tests indicate a clot is present, the doctor will make a recommendation regarding treatment. Depending on the location of the clot, the patient may need hospitalization. Medical or surgical care will be managed by a team of physicians which may include a primary care physician, internist, vascular (blood vessel) surgeon, or hematologist (blood disease specialist).

    Treatment may include:

    • Medication. A blood-thinning medication is usually prescribed to help prevent additional clots from forming.
    • Compression stockings. Wearing fitted hosiery decreases pain and swelling.
    • Surgery. A surgical procedure performed by a vascular specialist may be required.

    Complications of DVT
    An early and extremely serious complication of DVT is a pulmonary embolism. A pulmonary embolism develops if the clot breaks loose and travels to the lung. Symptoms of a pulmonary embolism include:

    • Shortness of breath
    • Chest pain
    • Coughing up blood
    • A feeling of impending doom

    A long-term consequence of DVT is damage to the vein from the clot. This damage often results in persistent swelling, pain and discoloration of the leg.

    Preventative Measures
    For those who have risk factors for DVT, these strategies may reduce the likelihood of developing a blood clot:

    • Take blood-thinning medication, if prescribed.
    • Reduce risk factors that can be changed. For example, stop smoking and lose excess weight.
    • During periods of prolonged immobility, such as on long trips.
      • Exercise legs every 2 to 3 hours to get the blood flowing back to the heart. Walk up and down the aisle of a plane or train, rotate ankles while sitting, and take regular breaks on road trips.
      • Stay hydrated by drinking plenty of fluids; avoid alcohol and caffeine.
      • Consider wearing compression stockings.
  • Computed Tomography - CT Scan Of The Foot

    Your doctor may order a computed tomography examination to aid in the diagnosis and treatment of your foot and ankle problem. Computed Tomography (CT) imaging, also known as "CAT scanning" (Computed Axial Tomography), combines the use of a digital computer together with a rotating x-ray device to create detailed cross sectional images or ""slices"" of the different parts, particularly bony structures, of the foot and ankle. This test helps to delineate the structures of your foot and ankle and can give your doctor 3-D visualization of these structures to aid in your treatment. For many patients, CT can be performed on an outpatient basis without requiring admittance to a hospital. CT imaging is commonly ordered for the following foot pathologies:

    • Bone Tumors
    • Fractures - acute and stress fractures
    • Non-unions or delayed unions
    • Infection
    • Foreign Bodies
    • Degenerative and rheumatoid arthritis
    • Angular deformities
    • Flat feet
    • Cavus feet
    • Post-operative monitoring
    • Avascular necrosis

    During the procedure, you will lie very still on a table. This table passes your foot and ankle through the x-ray machine, which is shaped like a doughnut with a large hole. The machine, which is linked to a computer, rotates around the patient, taking pictures of one thin slice of tissue after another. The length of the procedure depends on the size of the area to be x-rayed. The computer then processes images from these x-rays. The final image, called a "computed tomogram" or "CT slice," is displayed on a cathode-ray tube (CRT), a device similar to a television picture tube and screen. This image can be recorded permanently on film or can be stored on magnetic tape or optical disk.

    Computed tomography offers some advantages over other x-ray techniques in diagnosing disease, particularly because it clearly shows the shape and exact location of soft tissues and bones in any "slice" of the foot and ankle. CT scans help doctors distinguish between a simple cyst and a solid tumor and any involvement of the bone. CT scanning is more accurate than conventional x-ray in determining the stage (extent) of some bone tumors. Information about the stage of the disease helps the doctor decide how to treat it.

    Spiral CT scanners are one of the latest innovations. They use continuous scanning to generate cross-sectional slices and make a set of 3-dimensional images. Spiral CT has decreased the time it takes to produce tomographic pictures.

    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. Patients are encouraged to bring something to read or do in case there are any delays prior to their CT exam. Patients should wear comfortable, loose fitting clothing for their CT exam. Some people may be concerned about the amount of radiation they receive during a CT scan. It is true that the radiation exposure from a CT scan is slightly higher than from a regular x-ray. Because of the radiation exposure, pregnant women should not have a CT exam or any x-ray examination, especially if the woman is in her first trimester (first of three-3 month periods of pregnancy). Depending on the condition, there may be other exams available, such as ultrasound, to help diagnose a medical condition. Pregnant women should always inform their imaging technologist or radiologist that they are pregnant, or may be pregnant.

    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.

  • Compartment Syndrome

    Each of the muscles in the lower leg are contained in what is called a muscle compartment. Just like an orange or grapefruit, where the fruit is divided by fibrous sheaths into identifiable sections, the muscles of the lower leg are also divided by fibrous sheaths into identifiable muscle compartments. There are four muscle compartments in the lower leg: two in the back of the lower leg (i.e. posterior compartments), one on the front of the lower leg (i.e. anterior compartment) and one on the outside of the lower leg (i.e. lateral compartment). Each of the four muscle compartments contain at least two individual muscles, which are surrounded by the fibrous sheath which wraps around the muscles of the compartment.

    Because of the arrangement of the muscles of the lower leg into four compartments, an individual can develop two types of compartment syndrome: acute and chronic. Acute compartment syndrome is caused by direct trauma to the lower leg, such as that occurs during a motor vehicle accident where possibly one of the leg bones is broken. Blood rushing into the muscle compartment has no way to escape, causing a relatively sudden rise in the pressure in the muscle compartment. The increased pressure inside the muscle compartment can become so high that it clamps down on the arteries and nerves going through the leg into the foot. The result may be a loss of pulse and blood supply to the foot, loss of nerve function to the foot, and severe pain. Acute compartment syndrome requires immediate surgical attention or the individual may develop permanent deformity and disability in the leg and foot.

    The more common form of compartment syndrome is seen in athletes who exercise heavily and is called chronic exertional compartment syndrome (CECS). CECS is caused by the increase in pressure in the muscle compartment, which results from the muscles actually expanding in volume because of the increased blood flow to the muscles during exercise. If the sheath or compartment wall is particularly tight and thick, then as the athlete's muscles become larger over time from exercise the muscle compartment will become tighter. The compartment at the front of the leg is the most common muscle compartment to be affected by CECS and the pain that results is thought by many athletes to be shin splints. For runners, pain from CECS will generally occur within 20-40 minutes into a run and the pain may become so severe that continuing exercise past that point is impossible.

    Diagnosis

    A thorough history and physical examination must be made of the individual with suspected chronic exertional compartment syndrome. The podiatrist will be most interested as to the time during exercise that the pain starts in the leg, where the pain is located, and whether the pain dissipates somewhat with rest. The symptoms from CECS generally starts at the same time or at the same mile mark during running and also usually gets better soon after as the individual stops exercising.

    During the physical examination, the podiatrist will inspect the leg to determine which muscle compartment is affected and try to rule out any other pathology in the same area such as stress fractures, muscle strain, tendinitis, or shin splints. Additional tests such as x-rays, bone scans or MRI scans may be ordered depending on the most likely cause of the pain. Even though the podiatric physician can diagnose CECS relatively confidently by taking the proper history and physical of the patient, the only certain way to diagnosis the condition it is to have the muscle compartmental pressure measured at rest, during exercise and after exercise. Most doctor's offices do not have the special instrumentation to make this diagnosis and often the patient must be sent to a large hospital or sports clinic to have the test performed.

    Treatment

    Chronic exertional compartment syndrome may be treated conservatively by modifying the type, duration and frequency of the sports activity that causes the pain. The condition is often successfully treated by altering the surfaces the individual runs on and the shoes they run in. In addition, CECS sometimes responds to altering the function of the muscles of the lower leg with in-shoe custom supports such as functional foot orthotics. If all conservative measures do not resolve the pain from CECS adequately, the podiatrist may refer the patient to an orthopedic surgeon for possible surgical release of the sheath surrounding the muscle compartment. In general, most patients who have surgical release of the muscle compartment sheath are able to resume unrestricted exercise within a few months of the procedure. Many notable athletes have had the compartment release surgical procedure performed and have returned to training without pain or limitations.

  • Chemical Neurolysis For The Treatment Of Neuromas
    The chemical destruction of the nerve, called neurolysis, is an older form of treatment that has recently come back into vogue. This treatment requires a series of injections of ethanol mixed with a local anesthetic. The injections are given into the area of the neuroma. Nerve tissue has a natural affinity for ethanol, and it is readily absorbed into the nerve. Ethanol, however, is toxic to nerve tissue and with repeated exposure, will destroy the nerve. The rate of success is variable, but has been reported to be over 60%. Many insurance plans will not pay for weekly injections and require the doctor to wait a minimum of ten days between injections before they will reimburse for the procedure. This likely reduces the rate of success for this treatment, because during the time between the injections, the nerve will attempt to repair itself. One way to solve this delay is for the patient to pay for those injections not paid for by the insurance plan. The disadvantages for this form of treatment are the need for repeated visits to the doctor’s office, and the occasional pain in the area of the injection the following day or two after it has been administered. The advantages to this form of treatment is that it requires a minimal amount of time off of work and the overall cost as compared to the surgical removal of the nerve. If this form of treatment fails, then surgical removal is the only option that remains.
  • Charcot Joint Disease (Neuroarthropathy)

    Charcot joint disease was given its name by the French neurologist Jean-Marie Charcot in 1868. He noted a bizarre pattern of bone destruction in patients with tertiary syphilis and absent sensation. In 1936, William Jordan described a similar pattern in patients with diabetes.

    Theories as to the cause of the Charcot joint disease abound. However, certain predisposing factors appear to be necessary in order for Charcot to develop. First, peripheral sensory neuropathy or total absence of sensation must be present. Second, circulation is most commonly normal. Third, there is often a history of a preceding injury. This is often so minimal the patient is unable to recall any injury or trauma.

    Who Gets Charcot?

    Charcot joint disease was originally described in patients with tertiary syphilis and absent sensation. However, once penicillin was discovered, the incidence of syphilis dropped dramatically. In general, any disease process that results in loss of sensation in the lower extremity can lead to Charcot joint disease. Today, the leading cause of Charcot joint disease is diabetes mellitus. It is estimated that 1 out of 700 patients with diabetes will develop Charcot joint. Other entities, which can lead to Charcot joint, include: chronic alcoholism, leprosy, hereditary insensitivity to pain, syringomyelia and multiple sclerosis.

    A second key component to the development of Charcot is the history of a preceding injury to trauma to the foot or ankle. Often this injury goes undetected because of a lack of normal sensation. Additionally, because of poor sensation, the injury may not be perceived to be serious. Consequently, the patient will continue with normal or near normal activity leading to further fracture and dislocation of the involved joints and bones.

    Patients who develop Charcot joint will also have good to excellent circulation to their feet. It is uncommon for patients with significant peripheral vascular disease to develop Charcot joint disease.

    What are the Symptoms?

    Patients who develop Charcot joint disease most commonly notice unexplained swelling in their foot or ankle. Because of underlying loss of sensation, this swelling is often painless. On occasion, there may be redness localized to the top of the foot or ankle. There will also be increased warmth to the foot, indicating localized inflammation. Rarely will there be bruising unless the injury is significant.

    Because Charcot joint disease shows swelling and redness, it is often misdiagnosed. The most common misdiagnoses include: cellulitis, osteomyelitis, tendonitis and gout. Failure to diagnosis and treat this entity early and appropriately can lead to foot and ankle deformity.

    Diagnosing Charcot Joint Disease

    The diagnosis is primarily based on the clinical examination. A diagnosis of Charcot joint must be considered in patients with diabetes who present with a warm, swollen foot or ankle without pain. Another critical feature in the diagnosis of Charcot joint is the presence of crepitus or "grinding" in the involved joints. This represents the actual unstable bone fragments moving against each other.

    X-rays at this stage will often confirm the diagnosis, as these will often show fragmentation of bone and disruption of joints. Occasionally, if the x-rays fail to show any disruption and a diagnosis of Charcot joint disease is still being considered, bone scans can be helpful.

    Special studies such as CT scans or MRI are rarely necessary to make the diagnosis. A CT scan can be useful if reconstructive surgery is planned. An MRI can be helpful if an infection with abscess formation is suspected.

    Treatment

    Early diagnosis and treatment is critical to a successful outcome. Once the diagnosis of Charcot joint disease is made, initial treatment should consist of total non-weightbearing and immobilization of the involved extremity. This often requires the use of crutches or a walker. Additionally, a removable cast or brace to protect and immobilize the foot and ankle may be necessary. The duration of non-weightbearing and immobilization will depend on the joints affected and the degree of destruction. As a rule, the larger the joint, the longer the duration of non-weightbearing needs to be.

    Serial x-rays and resolution of the clinical features of the disease determine the healing of the involved joints. Clinically, one would expect to see reduction of swelling, decrease in skin temperature and decrease in joint crepitus. On x-rays, one would expect to see resorption of bone debris and fragments with deposition of new bone and fracture healing. Protected weightbearing may be initiated when the clinical features of the disease show improvement, especially loss of joint crepitus. Weightbearing can be increased gradually as long as there is no re-exacerbation of the disease.

    When foot and ankle deformity develops, custom orthoses and special shoes may be necessary to prevent foot ulcerations and provide stability during ambulation. When ulcerations develop and resist conservative treatment, surgery may be necessary to prevent loss of the foot. Additionally, if there is severe instability, reconstructive surgery of the foot and ankle may be necessary to provide a stable platform for ambulation and to avoid lower leg amputation.

    Complications

    The most common complication of Charcot joint disease is foot and ankle deformity. This can occur even following early and appropriate treatment. This typically results from significant bone and joint destruction that the functional integrity of the foot is sacrificed. Chronic ulcerations may occur as a result of these deformities. Surgery may be necessary to prevent limb loss. Another complication that may occur is instability of the foot and ankle during ambulation. This once again is related to the joints affected and the degree of bone destruction. Severe instability can lead to lower leg amputation. Major reconstructive surgery may be necessary to prevent this complication of Charcot joint disease.

  • Charcot Foot

    What Is Charcot Foot?
    Charcot foot is a condition causing weakening of the bones in the foot that can occur in people who have significant nerve damage (neuropathy). The bones are weakened enough to fracture, and with continued walking the foot eventually changes shape. As the disorder progresses, the joints collapse and the foot takes on an abnormal shape, such as a rocker-bottom appearance.

    Charcot foot is a very serious condition that can lead to severe deformity, disability, and even amputation. Because of its seriousness, it is important that patients with diabetes—a disease often associated with neuropathy—take preventive measures and seek immediate care if signs or symptoms appear.

    Causes
    Charcot foot develops as a result of neuropathy, which decreases sensation and the ability to feel temperature, pain, or trauma. Because of diminished sensation, the patient may continue to walk—making the injury worse.

    People with neuropathy (especially those who have had it for a long time) are at risk for developing Charcot foot. In addition, neuropathic patients with a tight Achilles tendon have been shown to have a tendency to develop Charcot foot.

    Symptoms
    The symptoms of Charcot foot may include:

    • Warmth to the touch (the affected foot feels warmer than the other)
    • Redness in the foot
    • Swelling in the area
    • Pain or soreness

    Diagnosis
    Early diagnosis of Charcot foot is extremely important for successful treatment. To arrive at a diagnosis, the surgeon will examine the foot and ankle and ask about events that may have occurred prior to the symptoms. X-rays and other imaging studies and tests may be ordered.

    Once treatment begins, x-rays are taken periodically to aid in evaluating the status of the condition.

     Non-Surgical Treatment
    It is extremely important to follow the surgeon’s treatment plan for Charcot foot. Failure to do so can lead to the loss of a toe, foot, leg, or life.

    Non-surgical treatment for Charcot foot consists of:

    • Immobilization. Because the foot and ankle are so fragile during the early stage of Charcot, they must be protected so the weakened bones can repair themselves. Complete non-weightbearing is necessary to keep the foot from further collapsing. The patient will not be able to walk on the affected foot until the surgeon determines it is safe to do so. During this period, the patient may be fitted with a cast, removable boot, or brace, and may be required to use crutches or a wheelchair. It may take the bones several months to heal, although it can take considerably longer in some patients.
    • Custom shoes and bracing. Shoes with special inserts may be needed after the bones have healed to enable the patient to return to daily activities—as well as help prevent recurrence of Charcot foot, development of ulcers, and possibly amputation. In cases with significant deformity, bracing is also required.
    • Activity modification. A modification in activity level may be needed to avoid repetitive trauma to both feet. A patient with Charcot in one foot is more likely to develop it in the other foot, so measures must be taken to protect both feet.

    When is Surgery Needed?
    In some cases, the Charcot deformity may become severe enough that surgery is necessary. The foot and ankle surgeon will determine the proper timing as well as the appropriate procedure for the individual case.

    Preventive Care
    The patient can play a vital role in preventing Charcot foot and its complications by following these measures:

    • Keeping blood sugar levels under control can help reduce the progression of nerve damage in the feet.
    • Get regular check-ups from a foot and ankle surgeon.
    • Check both feet every day—and see a surgeon immediately if you notice signs of Charcot foot.
    • Be careful to avoid injury, such as bumping the foot or overdoing an exercise program.
    • Follow the surgeon’s instructions for long-term treatment to prevent recurrences, ulcers, and amputation.
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