Hyperhidrosis, or excessive sweating, can be localized to one area or it may be generalized. In the localized type, the most common sites are the palms and soles of the feet. The cause of the excessive sweating is not well understood. There is an emotional component to it in some but not all cases. The excessive moisture contributes to athlete's foot and plantar wart infections. There are no good oral medications for the control of hyperhidrosis. Topical anti-persperants are of little value. A prescription topical medication called "Dry sol" is of some value. This medication works best if applied to the feet before going bed, then wrapping the feet in plastic wrap and wearing socks. This should be done three to four nights in a row. Although this is not a cure for the problem, it does provide temporary relief and is useful as part of the treatment plan for athlete's foot and plantar warts in patients who suffer from hyperhidrosis.

A subungual exostosis is a bony prominence that can occur under the toenail. They generally are a result of some form of trauma to the toe that results in the formation of bony irregularity or prominence. When they are symptomatic, removal of the spur is the treatment of choice. Additionally other small tumors called osteochondromas andenchondroma can also form in the bone beneath the toenail as well as in other bones in the body.

An osteochondroma is a benign bone tumor that accounts for 50% of all benign bone tumors. They have a predilection for the long tubular bones of adolescents and young adults. Its peak incidence is in the second decade of life with a male to female ratio of approximately 2:1. They are generally painless or minimally painful unless they cause irritation to the surrounding tissue. When they are in the bone beneath the toenail they can deform the toenail and cause an ingrown toenail. The treatment of symptomatic osteochondromas is surgical excision. The final diagnosis is made after the bone tumor is removed and examined by a pathologist. Recurrence of the tumor is possible following their removal. Hereditary multiple exostosis (osteochondromatosis) have a prominent hereditary incidence which affects males more often then females. The disease is characterized by the presence of multiple exostosis, which are frequently bilateral and somewhat symmetrical and usually make their appearance during childhood or adolescence.

Enchondroma is a fairly common benign cartilaginous tumor, which is the most common bone tumor of the hands and feet. They affect patients in a wide age range with no sex predilection. When they occur within the small tubular bones the tumor can involve large portions of these bones, causing thinning of the cortex of the bone. This can weaken the bone and cause it to break spontaneously. When they occur in the small bone in the end of the toe they can cause pain that may mimic the pain of ingrown toenails. Ollier's disease, also known as enchondromatosis, shows a strong predilection for the small bones in the hands and toes (phalanges) and the long bones behind the phalanges called metatarsals. It is often shows an asymmetric involvement, tending to affect one side of the body more than the other and has a propensity to transform into a malignant sarcoma. Maffucci's syndrome is a very rare form of enchondromatosis associated with multiple soft tissue hemangiomas. This tumor has a greater predilection for the hands and feet, and has a greater toward malignant transformation than Ollier's disease.

We discussed fitting infants' shoes in the last article, now your child is past the infant stage and into preschool. Children have usually developed their natural gait by this time, and are running and making lateral movements. At this stage children would rather be running than walking. Being more active requires a different type of shoe and different fitting of the shoes. The growth pattern will change, depending on the child, from a steady growth about every three months, to a spurt pattern. The foot may not grow for a period of time and suddenly grow a size or more in a short period of time. Due to the fact every child is different it is impossible to predict this change in growth pattern. The parent should check, or have a shoe fitter check the child's shoes every two or three months.

Most children of this age range are now attending a preschool, daycare, or mother’s day out program. It is natural for the child to desire the popular shoes that the other children are wearing. Unfortunately because all feet are different the most popular shoe may not be the best for your child's feet. The style of children's shoes often follows the style of adult shoes, but fashion and function often do not go together. The requirements of a child's foot are quite different than that of an adult foot, so adult styles on a child's foot may be a poor choice. An example of this would be the clog style shoe that is popular now. A child who is running and climbing cannot keep this type of shoe on during normal daily activities. Another would be the slipon style of athletic shoe that is becoming popular with adults. A slipon shoe for a child must be fit shorter that usual in order to keep the shoe from slipping off of the foot. This means that the shoe must be replaced more often than a traditional lace athletic shoe.

No two feet are alike. Some are narrow, some wide, and they vary in the overall shape. Style and shapes of shoes should match the shape of the foot. Compatibility is very important in fitting the foot. The shoe may be the proper size but the shape of the last is wrong for the foot. For example, a narrow foot would not do as well in a heavy sole, broad toe style. Wider feet would be better suited for this type of shoe. Children wear their shoes differently. Some shoes will look new after three months wear while other will look totally worn out after three weeks. How your child wears his/her shoes should be a consideration when fitting the shoes. For the child that is hard on his/her shoes, a heavier weight shoe will make a difference in how long the shoe will last.

Due to the wide variety of shoe and foot shapes, and due to the fact that right and left feet are different sizes, the perfect fit does not exist. There are some things you should check when fitting the shoes: toe room, width, throat room, heel fit, anklebone clearance, and compatibility of shoe and foot. The following are guidelines you can use when fitting your child's shoes. Remember fitting is an art not a science, it takes practice and experience.

Toe Room: Generally there is one third inch between sizes. Leaving one-third to one-half inch in the toes will allow for a whole size or size and one half of growth room. Be sure that this room is allowed on the larger foot. If the shoe is too long, the break across the vamp (front of the shoe at the ball) will be at an angle instead of straight. The break or bend across the vamp may also be deeper on a shoe that is too long causing irritation across the top of the toes. As the shoe is worn, the toes will have a tendency to turn up.

Width: Shoe width is probably the most important part of fitting a shoe, but is ignored by most parents. Most parents want the shoe to fit with lots of toe room so that it can be worn for a longer period of time. However, if the shoe is not wide enough, then it will be outgrown in width long before the length becomes a factor. Foot growth is not in equal proportions; the toes are one fourth and heel to ball is three fourths of the total growth. If the shoe is too narrow then the foot cannot grow forward in the shoe, and length becomes less important.

You should be able to lift the leather off of the top of the foot by gently squeezing across the ball of the foot. One-sixth to one-quarter of an inch should give the child ample room for forward growth in the shoe. Be sure that the little toe is not cramped or turned under. Narrow feet are much more difficult to fit than wide feet because most manufacturers do not make narrow widths. Guidelines for fitting a narrow foot are the same, but you may have to try many more styles to find one the fits narrow enough for your child's foot. Frustrated parents will ask, "Will it hurt my child’s foot to wear a shoe that is too wide?" The answer depends on the length of time the shoe is going to be worn and how wide it is. The foot will move constantly in a shoe that is too wide. The motion can cause irritations such as calluses and in some cases blisters. Sometimes insoles can be used to take up the extra space in the shoe, but it is difficult to find them in children's sizes.

Throat Room: The throat of the shoe is on the top where the foot meets the shoe. If there is not enough room between the foot and the shoe in the throat, then the foot will not be able to grow forward in the shoe. The tip of the first finger should be able to be inserted between the foot and the shoe in the throat. This will allow ample room for the forward growth of the shoe. Of course different styles of shoes will require different amounts of room. You cannot allow that much room in a slip-on shoe or loafer. If you do, the shoe will slip off as easily as it slips on. A buckle or Mary Jane style has a low cut vamp but you should still allow room on the top where the shoe and foot meet. The strap will allow for some adjustment of heel fit.

Heel Fit: Your mother always told you to make sure the heel doesn't slip when you are trying on new shoes. A little looseness in the heel is not a bad thing. If the heel is too tight however, you will be guaranteed a blister. Constant pressure on the heel will cause the body to build up a fluid to cushion the spot. Excess room will also cause problems, but just a little room will allow for more natural foot movement. Use caution on sling back shoes and clogs. These styles offer no lateral heel control. As the child runs, the heel will slip to the side, increasing the chances of twisting an ankle.

Anklebone: The anklebone on the outside of the foot is lower on some children and can be a problem area. Athletic shoes with padded collars usually take care of this problem. With dress shoes that are harder and stiffer it can be a source of irritation. Check to see that the topline of the shoe comes above the anklebone or well below it. Sometime a felt heel lift will help until the topline softens.

Compatibility: There are many styles of shoes on the market today, and your child will want the one that is the most popular. However, is that the best shoe for his/her foot? A shoe can be the right size but be totally wrong for the foot. Be sure the shape, or last, of the shoe match the shape of the foot. Matching the shoe and foot shape will be more comfortable for the child and the shoe will look and wear better.

Several months ago a mother brought her daughter in with a pair of shoes that had been purchased at a specialty athletic store. Due to the fact that the child was in a school sponsored activity, the shoe was required for the uniform. The child had bunions and the beginning of hammertoes, and the shoes were very painful for her. The mother inquired about adjustment to the shoes that would allow the child to continue with her activity. After several adjustments on the shoes, they were less painful. However they still did not fit, nor were they compatible with the child's foot. Children will wear shoes that are popular or required for an activity whether they fit or not. It is the parent's job to assist the child in making correct choices. If proper fitting is started at an early age, then the foot will grow to its adult shape with few problems. Hopefully incidents like the one above will be avoided.

article written by: Kirk Watson

In thirty years of fitting children's shoes I have seen many changes in the shoe industry. This is especially true in the style of shoes that parents are purchasing for their babies. Hard leather soles and stiff uppers were the rule many years ago. Since that time we have progressed to rubber or PVC soles. Soft leather uppers that conform to the foot and offer greater freedom of movement are now recommended. Narrow, medium and wide widths have since replaced the traditional B,C,D,E,EE. With all the changes in the children's shoe industry one constant remains, no matter what style of shoes you choose for your baby, they need to fit properly.

Foot problems normally found in adults are now being found among children. I have observed this more in the last ten years. In most cases this can be attributed to ill fitting or improper footwear. Often parents don't know how a shoe should fit or what areas of the shoe need to be checked for proper fitting. Hopefully this article will help insure that parents are more aware of how to fit children's shoes.

Shoes are really not required until the child starts to pull up and cruise around objects. You will notice they stand on their toes and try to edge themselves around a table, sofa, or anything else they can hold onto. Toe gripping allows them to balance themselves and learn to take steps.

Babies feet are very soft and pliable with padding surrounding the foot. This is nature's way of protecting the underlying foot structure. This means the foot is thick, with the heel being narrower. Because of the narrower heel and the flexibility of the foot, high tops are generally better to keep the shoe on the foot. This will also allow for the shoe to be fit a little larger than a lower top shoe.

Fitting shoes is not a science, but an art. It takes practice and experience with different types of shoes and feet. Using the following guidelines, you will be better able to fit your child with the proper shoe size.

Measuring

Both feet should be measured in a standing position if possible. Feet are flexible and will expand in length and width with body weight. There are three measurements taken from the standard branock device. They are length, width and arch length. It is very important to understand that the size the foot measures is not necessarily the size shoe that the child will wear. Differences in construction, materials, last (the form the shoe is made on) and sizing systems will determine the actual shoe size. Note any differences in the sizes of the feet and be sure to fit the largest foot.

Length

How much length is necessary for growth? Generally there is one third of an inch between sizes, and one sixth of an inch between half sizes. Allowing one third inch growth translates to one shoe size. This allows two to three months wear for an infant. Keep in mind the growth rate will vary with individual children. Purchasing shoes that are too large is likely to cause tripping of an already unstable walker.

Width

Judging the proper width of a shoe is not as obvious as the length. Since the length and width of a shoe are proportional, the width will increase along with the length. Width increases about one-fourth inch per full size. Many manufacturers only make mediums. Try to find brands that are made in multiple widths. Remember that the foot is three-dimensional. Two of those dimensions are width and thickness. The thicker the foot or higher the instep, the wider the shoe has to be to accommodate the foot. As we discussed earlier, infant's feet are heavily padded and thick by nature's design requiring a wider shoe. Inserting the tip of the first finger between the shoe and foot at the instep is the first gauge of how well the foot is fitting the width of the shoe. If the finger will not fit then the shoe is not wide enough. Room in the throat of the shoe is critical to allow for the forward growth of the foot into the shoe. Since the growth of the foot is three-fourths heel to ball and one fourth toes most infants will outgrow the width of the shoe before they do the length. Parents will often check the length but not width of shoes. Using the thumb and first finger, at the ball of the foot, gently pull the leather in a lifting motion up from the foot. There should be enough room to lift the shoe material off of the foot slightly, but not in excess. Check the inside and outside of the foot for pressure points and cramped toes especially the little toe.

Heel

If you are fitting a high-top walking shoe on your baby, the heel fit is not a major concern. The heel is covered and the shoe will stay on well. On a lower shoe the heel should stay in the shoe with out popping out when the baby walks. Tightness in the heel will cause more problems than if the shoe is a little loose in the heel. A little looseness is permissible, but not a large gap between the heel and the shoe.

Walk Test

If the child is not walking on their own yet, let them pull up on a chair or fitting stool. All checks on the fit of the shoe should be done with the child standing. Feet are not static but dynamic. Standing will allow the foot to expand in the length and width to the normal size it will be when walking. If the child is walking, let them take a few steps and watching their balance. Take note of the break in the shoe. It should be straight across the ball of the foot. A deep break (excess wrinkle) or breaking at an angle would indicate that the shoe is too wide. Breaking forward of the ball of the foot would indicate that the shoe is too long. Check the shoe again after the child has taken a walk in them and the foot has relaxed and set in the shoe.

Other checks

On a low top, shoe material should either cover the outside anklebone or be far enough below the bone so as not to cause irritation. Always check the inside of the shoe before putting your child's shoes on. Nails, tacks, paper, plastic tags are some of the objects I have found in shoes over the years.

Fitting your child now with the proper size and style of shoe will help prevent possible foot problems in years to come. Longer life spans and more active lives mean more wear and tear on the feet. Don't let your child be like many adults that say, "I wish I had worn shoes that fit when I was a child." "My feet would not be in such bad shape now." If are you able find a local merchant that still knows how to fit shoes, then please make use of his knowledge and experience. If not, remember these tips the next time you buy shoes for your baby.

Written by Kirk Watson

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.