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Tuesday, September 30, 2014

What? You still have heel pain??? You need to read on and see what "2 Pods and a Microphone" have to say!

So, we have hit this subject matter on  more than  on one occasion.  As foot and ankle surgeons, it is not uncommon in a typical day to see at least 15 patients that have heel pain or plantar fasciitis.  These people often present with the same core set of symptoms in general. First and foremost, they always describe first step in the morning pain or pain after they have been resting and get up pain.  Some people describe pain in their feet after being up and standing for more than a couple hours, with their pain being concentrated basically at their heel on the bottom.

People find it hard to believe that stretching, icing and support can be the perfect combo to relieve and help get rid of their heel pain, but it's true!!!!The plantar fascia is a tight band on the bottom of the foot that connects the heel bone, the calcaneus, to the long flexor tendons to the toes. What I always tell patients when they come into the office with heel pain or plantar fasciitis, is that even though it hurts so darn bad the cure really does revolve around stretching believe or not, in most cases.  Sure it can require a medicine by mouth or even a shot with some extra support in shoe gear but it is usually a simple fix.

The fix is simple but, depending in how long it takes you to seek help to get better, could be the deciding factor on how long it actually takes you to get better.  The sooner you seek care, start the stretching exercises and put good support in you shoes, the sooner you are on the road to recovery.

Steps to getting rid of your heel pain:

1.  No barefoot for the next 6-8 weeks
2.  Static calf stretches (if you do not know what that means check out our Pinterest Page Heel Pain          Helpers http://www.pinterest.com/cafcdpm/heel-pain-helpers/


3.  Get a 16-20oz bottle of water, freeze it and take it out of the freezer at least 2x's a day and roll it           back and forth under your foot with a thin sock on or barefoot(I tell patients all of the time that           this is like physical therapy with out a copay)
4.  Look at your shoes, if they have no arch support ditch them or get a really good arch support like our over the counter arch supports for heel pain(shameless plug, but they are really good:) They retail for $63 and go by shoes size you can order your pair on our website   at http://centeranklefootcare.com/
5.  Of course, if you can take an anti-inflammatory and you have no drug interactions that will also help this feel better for you.



Stretching Exercises Stick Figure Illustrations below
(by Dr, McGowan, she's a podiatrist not an artist, don't judge people)





If you have heel pain or plantar fasciitis, and it has been longer than two weeks you should see a podiatrist.  If you live in Central Florida, of course the podiatrist you should see is Dr. McGowan or Dr, Henne! Our webpage is http://centeranklefootcare.com/index.html where you can explore more about all the different services we offer at all 3 of our locations.

Our doctors also have a weekly podcast that is called "2 Pods and a Microphone" where they discuss all different topics about foot and ankle health.  You can actually subscribe to their podcast on iTunes at https://itunes.apple.com/us/podcast/2-pods-a-microphone/id909176500?mt=2    or listen here to the first podcast of "2 Pods and a Microphone" below:


Listen above to the first Podcast of "2 Pods and a Microphone" this is our first podcast ever, before we figured out how to reduce noise or really edit, but still some really great information to help you differentiate true heel pain from a pinch nerve in the back causing symptoms in the feet.  Enjoy!

If you have questions about a foot or ankle problem, we would be happy to answer it in one of our podcasts or blog.  You can leave a comment on our blog or a go to our webpage at http://centeranklefootcare.com/id78.html fill out the questionnaire and  we will answer your question on the air!



Sunday, September 28, 2014

Week 4 into Week 5: 2014 NFL Football Stephen Tulloch Knee Injury while celebrating a Sack of Aaron Rodgers. Cautionary Tale of Celebrating before the game has ended!!!

We are well into the 4th, going into the 5th week of 2014 NFL football season and everyone talking about their fantasy football teams. As we talk about every week on our "2 Pods and a Microphone" Podcast, injuries are a major focus. We always hear of players having concussions but there are definitely injuries of the lower limb that can keep players out for the season. My all time favorite knee injury I have ever heard of is the Detroit Lions Stephen Tulloch who injured his knee after celebrating a sack of Aaron Rodgers. I want to make it clear, that I never am happy when my fellow human hurts themselves after two knee surgeries myself after a way too long soccer career. But the way he did it totally deserves everyone to stand up and slow clap,  please see below and then you will understand!  






As of right now, we do not know the extent of Stephen Tulloch's  injury, and though his injury may not  be earth shattering to a fantasy football line up, it does raise the question of what would you do if it was your wide receiver or running back?  Below I have illustrated the knee joint and explain each of these ligaments. 

Here’s a quick explanation:

Anterior cruciate ligament (ACL): It is one of the four ligaments that attaches the front of the tibia to the femur and it is located inside the knee. It prevents the lower leg from sliding out in front of the upper leg. Tears of the ligament often result from frontal impact on knee or thigh when the foot is fixed. A test used to determine if your ACL is torn is called anterior drawer sign because the leg will slide forward like opening a drawer.

Posterior cruciate ligament (PCL): This is like the stronger brother of the ACL that helps hold the upper and lower leg together. This ligament prevents the lower leg from sliding out behind the upper leg. Injury usually happens by overextending the knee, such as a direct blow to the flexed knee or motor vehicle accidents (“dashboard injury”).

Medial collateral ligament (MCL): It is located on the inner surface of the knee connecting femur and tibia. Part of the ligament Stabilize the knee, promote locking of joint, and prevents the knee from bending inward. Tackling is a common cause of injury to this ligament.


As you can see with the picture to the above that the ACL and PCL cross each other inside the knee joint and that is why they are called the cruciate ligaments. I hope that this helps some people understand what it could mean for your fantasy football player.

Good luck to all:)

Saturday, September 27, 2014

Plantar Fasciitis, Will it stop your fantasy football player?

It's Sunday, it 11am and you are sitting comfortably and getting your last minute adjustments made to your fantasy football team. Then you see it, that capital P, for your rock star player being probable. Probable??? What kind of nonsense is that? Upon reading on, you read the two words Plantar Fasciitis.

If you are lucky, you have already had this in your lifetime so you know it hurts but can most likely play through the pain for a couple million dollars.

But actually, if you are one of the lucky ones who has never had this, you may not know if it is worth the risk to play the "P" player who has plantar fasciitis.  We figured as two foot and ankle surgeons that make up the "2 Pods and A Microphone" Podcast, we could fill you in on what is Plantar Fasciitis, and is it something you should bench your fantasy football player or take the chance and play them.

The plantar fascia is a tight band on the bottom of the foot that connects the heel bone, the calcaneus, to the long flexor tendons to the toes. What I always tell patients when they come into the office with heel pain or plantar fasciitis, is that even though it hurts so darn bad the cure really revolves around stretching believe or not in most cases.  Sure it can require a medicine by mouth or even a shot with some extra support in shoe gear, but this does not have to be a deal breaker for your fantasy football player.  I have 65 year old patients that can got from a 10 to a 1 on the pain scale with some simple steps.

Steps to getting rid of your heel pain:

1.  No barefoot for the next 6-8 weeks
2.  Static calf stretches (if you do not know what that means check out our Pinterest Page Heel Pain          Helpers http://www.pinterest.com/cafcdpm/heel-pain-helpers/
3.  Get a 16-20oz bottle of water, freeze it and take it out of the freezer at least 2x's a day and roll it           back and forth under your foot with a thin sock on or barefoot(I tell patients all of the time that           this is like physical therapy with out a copay)
4.  Look at your shoes, if they have no arch support ditch them or get a really good arch support like our over the counter arch supports for heel pain(shameless plug, but they are really good:) They retail for $60 and go by shoes size you can order your pair on our website     at http://centeranklefootcare.com/ )

5.  Of course, if you can take an anti-inflammatory and you have no drug interactions that will also help this feel better for you.



So again, this is very rarely a surgical problem and if you have a fantasy football player that is one of your top point earners week in and week out, this is not going to stop them.  The name is scary but is nothing to truly fear.

Listen to our "2 Pods and A Microphone" Podcast below, where we discuss NFL Week 4 Fantasy Football Lower Extremity Injuries.  Also we break it to our 10 year old daughter that is in the same Fantasy Football league as us, that mom's new addition to her team, tight end Larry Donnell scored 3 touchdowns against the defense her father told her to pick up.  We are just hoping she doesn't use the word collusion to her own parents:)

Thursday, September 25, 2014

Week 4 Fantasy Football Challenges and this weeks Bye week teams.


First and foremost, if you are new to fantasy football you need to check and make sure your team is not on a bye week!  So the following teams have a bye week this week:

Week 4 Bye week teams
  • Arizona Cardinals
  • Cincinnati Bengals
  • Cleveland Browns
  • Denver Broncos
  • St. Louis Rams
  • Seattle Seahawks

What does this mean to you? YOU NEED TO CHECK YOUR LINE UP! Make sure you have no one on your starting line up that is not playing.  This is going to be especially important during Weeks 4, 9 and 10. These are the weeks that the most teams are on a Bye week at one time.  

If you are like me, you probably have a couple really great picks that you drafted or have acquired from the waiver wire of the last couple weeks. Some of these players are not playing this week, so what do you do? Well my bench is not as deep as I would like it to be and I have had to be creative trying to figure out who I should pick up or drop for that matter. I always say trust your gut instinct but if your gut is wrong more than two times in a row then it is time to listen to the experts:) 

Right now I am following a couple of the pro-forecasters for NFL fantasy football on Twitter.  That's right folks, I said twitter!  My name is Michele McGowan and I am on Twitter. There it feels good to get that off  my chest.  But there are a lot of good credible people that give advice on Twitter. These are some of my favorites. 

Who to follow on Twitter:
@Stephania_ESPN 
-  @BleacherReport 
-  @ESPNMondayNight 
-  @ESPNNFL 
-  @NFLFantasyTalk 
@AroundTheNFL 
-  @Michael_Fabiano 

This list is in now way complete, as there are so many great people that just give this advice for free.  My husband gives advice for free too but for some reason I trust these people so much more:)

As two podiatrist and foot and ankle surgeons, Dr. Henne and myself can give you advice on injuries of the lower extremity for your fantasy football roster. We explain what the big foot or ankle of your start player can mean for the short term and long term.  Our Podcast is available on iTunes every Sunday morning, you can subscribe to our podcast on iTunes https://itunes.apple.com/us/podcast/2-pods-a-microphone/id909176500?mt=2 and have it automatically downloaded so you can listen for any last minute injuries of your players or go to our webpage at http://centeranklefootcare.com/id81.html and listen to the Podcast directly from the webpage.



Wednesday, September 24, 2014

Fantasy Football, Matt Cassel and why a Lisfranc's Fracture or Dislocation is season ending.




As I painfully watch Dr. Henne's favorite team in the NFL, the Minnesota Vikings, lose players for all different reasons, I feel the worst for Matt Cassel.  This past week when the Minnesota Vikings quarterback hurt his foot we immediately suspected some type of Lisfranc's injury.

A Lisfranc's tear of the ligament or fracture of the joint both are terrible injuries.  Usually the mechanism of force in this injury is the metatarsal bones being forced in one direction while the mid foot and rear foot bones are going another.  When there is not a fracture associated with a tear or strain, I find these injuries to be grossly under treated.
                                                     
Whenever I have an athlete in my office who presents with a swollen foot that has difficulty bearing weight I always get an x-ray.  If their history is one that involves someone falling on the foot or them recalling pain in their mid foot after a forced dorsiflexion of the foot I am suspecting a Lisfranc's ligament strain, fracture or dislocation.  If the x-ray is negative I send the patient for an MRI.  I feel strongly that we do these individuals a true disservice if we do not fully investigate these types of injuries.  Whether it is a 14 year old football player or an Olympic sprinter training in Clermont,  I believe the sequela of this type of injury under treated can lead to potential disability down the line.

If the MRI is positive for a Lisfranc's strain I will immobilize this patient in a cast and make them non weight bearing for 6-8 weeks.  I would then have them progress to weight bearing in a pneumatic walking cast for at least a month.  If there is a fracture of the Lisfranc's joint with no dislocation I may consider the same treatment as above but the non-weight bearing period of time may be a little longer based on the patients serial x-rays and clinical symptoms. But in many cases this becomes a surgical problem.

If the X-ray and MRI show a fracture with dislocation I believe surgical intervention is paramount for the individuals avoiding a rocker bottom foot deformity in the future. This is not a perfect procedure
and comes with its own set of consequences for future foot problems.  The surgical approach is determined based on the type of dislocation and fracture.  I usually will perform and open reduction with internal fixation to relocate the broken bones or pin percutaneously unstable joints.  Unfortunately for the patient, these screws that we put across the joints are only temporary and will require a second surgery for screw removal.

As you can imagine, the road to recovery after this type of surgery is arduous. For a world class athlete the road can be easier as the treatment received may be more expeditious, unlike the bureaucracy and hoops that the average Joe might have to go through in order to even get an MRI approved or come up with their new $12,000 deductible they have now due to the Affordable Health Care Act.(Sorry doctor rant over.)

Matt Cassel most likely will have surgery this week for his foot if he has a fracture or a dislocation of the Lisfranc's joint. This injury though will be season ending for him.  If he is your quarterback for fantasy football hopefully you caught wind of this prior to the wavier choices being picked and done. If not, hopefully, you have a really good back-up on your bench!

If you would like to keep up to date on the many types of injuries your fantasy football players may be faced with this season check out our webpage http://centeranklefootcare.com/id81.html home to the  "2 Pods & a Microphone" Podcast, where myself Dr. Michele McGowan and my partner in many ways Dr. Henne explore the injuries that matter to the feet and ankles to your fantasy football team:)

Tuesday, September 23, 2014

Diabetes doesn't have to equal amputation!

Podiatrist Play a Big role in Diabetes Prevention:
Despite being one of the most serious and costly complications of diabetes, foot complications can be effectively prevented. By implementing a care strategy that combines prevention, the multidisciplinary treatment of foot ulcers, appropriate organization, close monitoring, and education of people with diabetes and healthcare professionals, it is possible to reduce amputation rates by up to 85%.      
International Diabetes Federation (IWGDF), 2011

Diabetes doesn't have to equal amputation!

Every time I meet a new patient that has just been diagnosed with diabetes, usually Type 2 non insulin dependent due to the demographic I see, we usually have some type of conversation about limb loss.   It seems that all of these people have an uncle, aunt, parent or grandparent that has had an amputation.  So when these people are first diagnosed with diabetes their initial fear becomes the "A" word, amputation.

Sometimes doctors are not the best communicators with this type of patient.  With the type two diabetics, their should be some type of discussion about weight loss and the contribution their belly fat has to complicating this disease process.  I am always happy to discuss this with the patient when this may have been overlooked by their doctor who is trying to make sure that the patient doesn't die of something else.  

How I always describe the process of belly fats roll in the Type 2 non-insulin dependent diabetic to a patient so they can grasp what is going on in simple terms is as follows:
1. Your pancreas is working
2. When you eat, your pancreas is producing insulin
3. The insulin gets trapped in the fat cells closest to the pancreas itself
4. Since the fat cells are trapping your insulin, your blood sugars go up

I also explain the process of diabetic neuropathy to the patient, explaining what happens next, as the sugars
are not being met with the insulin.
1. Our body has a mechanism to try to counter the glucose in the absence of insulin
2. The Polyol Pathway kicks in and tries to reduce glucose but produces sorbitol
3. Our bodies are not efficient at clearing this and its other byproducts
4. The sorbitol will attach to the nerve endings and contribute over time to neuropathy symptoms

Why I explain this has a lot to do with my strong belief that if you can get the patient to understand a little they may be able to help themselves.  I am sure the patient will not go home and tell their family all about the Polyol Pathway and sorbitol. But they might just think about it, internalize it and try to help themselves.

When I have the uncomfortable conversation about their belly fat, I discuss the benefits of a simple 10 minute walk a day to start.  For some of these people, what comes along with the Type 2 diabetes and belly fat is aching joints and feet.  So exercise sometimes needs to be creative.  In Florida we have the advantage of almost year round pool usage which is great.  I encourage patients to walk in the pool or swim, giving less trauma to their already aching joints and feet.  They need to start somewhere and a little will go a long way in the beginning.  What the patient is really trying to do here is decrease their amount of insulin resistance. Exercise will help and hopefully help them loose the belly fat.

Diabetes does not have to equal amputation
This again is a topic that becomes paramount for the newly diagnosed Type 2 and Type 1 Diabetic patients.  The stigma of limb loss with diabetes is unavoidable.  But is has been documented throughout the literature, complications of diabetes to the foot and lower limb can be avoided with good preventive care.  Like most anything, at home prevention and patient mind set play an important role in patient outcomes.

I tell all of my newly diagnosed diabetic patients, that the patients that I wind up having to amputate a toe or part of their foot on are usually consults from the hospital, not current or past established patients.  The normal scenario is a patient that come through the emergency department of the hospital and gets admitted for a foul smelling wound.  The patient may have blood sugars that are regularly in the 300s and does not check their feet on a daily basis.  These two things alone are a recipe for disaster and I always stress that to my patients.

Compliance plays a huge role in whether someone I meet as a patient for the first time will actually go on to limb loss.  Obviously, if they are admitted with and infection that is so severe that the bone is infected and tissue is destroyed, they have already sealed their fate for potential limb loss.  But if the patient can follow instructions and work on improving their blood sugars and be compliant with wound care, they have a chance.

Top 4 reasons wounds do not heal
I preface this with the following, If a patient has any of the following 4 issues, it does not mean that the pressure, lack of blood supply, infection and smoking. 
wound will not heal, as I will explain below.  But having any of the following 4 as an issue and not making steps to change the situation will surely complicate the patients situation.  So the top 4 reasons wounds do not heal are:

Pressure, I always start with pressure. Since many of our diabetic patients with wounds have neuropathy, I explain this one first.  It only takes about 4 minutes of pressure for tissue necrosis and death to start to occur.  What that means is that when you are standing on an area that is callused or has an open pressure wound, after about 4 minutes we are starting the process to do further harm.  For the callus patient that can mean damaging the skin underneath the callus.  This can lead to a wound underneath the callus.  For the patient with an open wound this can lead to the wound getting bigger and deeper.  When a patient is checking their feet daily, they are more likely to notice and take care of these problems before they become bigger issues.  If they already have an established relationship with a foot doctor they can get in to the office be seen and treated.  Treatment for wounds caused by pressure revolve around offloading, an external means to remove pressure off the area.  We do this with padding, special shoes and special casting when needed.

Lack of blood flow I define as not being able to palpate pedal pulses in the office or a decrease or stenosis of blood flow that is not supplying enough blood to the foot.  Many of my diabetic patients I see for preventive foot care have this condition to their extremities but they have no open wound so it becomes less of an issue for them.  We focus at that point on prevention.  When someone walks in with an open wound and no palpable pulses the game changes.  This is the patient that needs a referral to a vascular surgeon before I can help them.  I never waste the patients precious time in this scenario.  If I can't feel their pulses and they have an open wound, I am sending them to the best vascular surgeons I know. They need blood to heal simple as that.


Infection
 is another area of the wound that must be assessed.  If there is a simple infection sometimes just an
antibiotic will do the job.  Often, though, many of these types of infections have a more significant effect on the soft tissue.   These wounds requiring multiple debridements to cut away dead tissue from the wound that
the infection has killed.  Theses are the patients that are typically admitted to the hospital, placed on IV antibiotics and have multiple trips to the operating room.  Until all of the infection is cleared it is impossible for the wound to heal.  Once we are certain that the wound is free of infection we can close the wound if there is enough soft tissue, if not we use many different wound care modalities to aid in the closure of their wound.

Smoking is the final topic I speak with my diabetic patients about to decrease their risk of complications.  Simply I state to my patients that they need to STOP SMOKING if they want to keep their limbs.  The damage that smoking does to the arteries, soft tissue and skin can make the difference between losing a limb or keeping it.


Dead horse but prevention is key
This a topic I literally try and beat into my patients.  I want patients to know that most of the terrible infections and amputation I perform are not in the compliant patient. The amputation rate in my practice for established diabetic patients, that were not seen for the first time in the emergency room or hospital, is very close to 0%.  My established patients, that are seen for regular diabetic foot check ups do not end up getting amputations.  We catch problems on these visits so that problems do not progress to a point where they get out of hand.

Below are my very generic but very effective tips on preventing foot problems when you are diabetic. I encourage patients to follow these guidelines and feel free to share them with friends or family members that also may benefit from this advice.  And I always my patients it is always better to be safe than sorry.

What can I do to better take care of my feet?

There are many steps you can take to greatly reduce the chance of major injury to your feet.
  • Visually check your feet and toes daily for any cuts, sores, blisters, bruises, bumps, infections, or nail problems, EVERYDAY.
  • Wash your feet daily using warm water and mild soap. Check the water temperature with your wrist to make sure it isn't too hot, and do not soak your feet for long periods or at all.
  • If you have dry skin, cover your feet — except between your toes — with petroleum jelly or cold cream before putting on shoes and socks.
  • Wear thick, soft, and loose-fitting socks and shoes that fit well and allow your toes to move. Rotate your shoes and do not wear new shoes for more than a few hours at a time.
  • Watch out for a thick seam in a sock, it can help cause ulcers on the tops or tips of the toes.
  • Cut your toenails straight across and don't leave sharp edges that could cut the next toe, they are too difficult to cut yourself or you have neuropathy or peripheral vascular disease, see a podiatrist.
  • Never go barefoot on the beach or anywhere else.
  • Have your feet checked at every doctor visit.
  • Do not sit with your legs crossed. Crossed legs can cut circulation to the feet.
  • Do not use tobacco products. Smoking impairs circulation.
  • check out more of our tips at:    http://centeranklefootcare.com/id7.html
Diabetic foot by the numbers:


  • Every 20 seconds a lower leg is lost due to diabetes globally
  • A majority of these amputations are preceded by ulcers
  • Only two-thirds of ulcers will eventually heal and the remainder may result in some form of amputation
  • Median time of healing for an ulcer is approximately six months
  • Each year, some 3.8 million adults die from diabetes-related cause
  • Diabetes is the fourth leading cause of death by disease globally
  • In 2011 it is estimated that 366 million people worldwide have diabetes
  • The number is expected to reach some 552 million by 2030
Ref: International Diabetes Federation (IWGDF), 2011  and  American Diabetes Association, 2012
2010 United States Census



Sunday, September 21, 2014

Week 3 Fantasy Football Ankle & Foot Injury Report and Emma's Football Picks for Week 3

This week we discuss NFL Week 3 important foot and ankle injuries that may effect your fantasy football line up this week. Listen to these two entertaining foot and ankle surgeons take on injuries and fantasy football.





Emma's Football Picks Week 3 video

Wednesday, September 17, 2014

Why do my feet hurt? Duh........IT'S YOUR SHOES!!!!!!!!!

As a foot and ankle surgeon, I see many people on a daily basis that come into the office with difficulty walking.  The cause of their difficulty stems from many different individualized problems.  However, many people do not realize that their shoes play a key role in why their feet hurt.  Not all shoes are created equally. I am not just bashing high heels here.( as I frequently do because I have a job where I get to wear pajama's(aka scrubs) and sneakers all day)  But many of the shoes we wear can do a real number on our feet.

Did you know that ill fitting shoes can contribute to: hammer toes, bunions, ingrown nails and plantar fasciitis(heel pain) just to name a few?  This can even be worse for the diabetic patient with neuropathy that has loss of their protective threshold.  For this kind of diabetic, an ill fitting shoe can lead to ulcerations and limb loss.  So it is probably no shocker that I spend most of my day educating people on the "right" kind of shoes to wear.

For people with developing ingrown nails, bunions and hammer toes, I try to impress upon them the importance of having enough room in the toe box. As you can see in my wonderful illustration(that is a little sarcasm folks, I'm playing around with doing my own illustrating) that most shoes have a toe box that curves in to put a little pressure on most peoples big and little toes.  Over time, continuing to wear shoes that put pressure on these areas can cause irritation to the nail fold, too much stress on the capsular tissue of  the great toe joint can contribute to a crowding in the toes that may cause hammer toes.  I will take you through each one of these and explain their treatment options.

The ingrown nail is a frequent flyer in a podiatry office.  These patients run the gamut from the 13 year old skateboarder who continues to hit his toe with his board to the 80 year old little lady with the tiniest little shoes on her feet that look like they are going to explode out of them at any second! If the nail is ingrown, I take the time to explain the behavior that most likely is causing the problem.  Repetitive micro trauma for the skater dude and ill fitting shoes for the little old lady.  I am a huge believer that if you don't correct the behavior, you will certainly have the problem again.

Usually the first sign of an ingrown nail is pain to the offending nail border.  This is quickly followed by redness to the nail border and then oozing of  yucky yellow brownish liquid.  It often amazes me at what stage people come in. Some people wait until the toe looks and smells really bad.  My recommendation is if you push on either side of your nail border and it is tender, it might be worth it to get it looked at to prevent all the other infection stuff that goes along with it.

There is a simple in office procedure that we can perform to remove the infected ingrown border permanently.  I always tell patients that, "It's going to hurt to numb the toe and that there is after care involved. They need to soak it it twice a day and keep it covered with triple antibiotic cream and a band-aide. I explain that it is going to ooze yucky stuff and they may not get back into some of their shoes for up to 5 weeks."  I really try and sell this:) But I do explain that it is a great procedure and they will not have to deal with it again.

The topic of shoe gear comes up, as I tell them the only loop hole for this coming back and being their fault is if they wear bad shoes! If they go back into a ill fitting shoe with pressure on the great toe, they will surely suffer the same fate.

I must say, as a female physician, the only time I am very unemphatic to my fellow sisters is when they come into my office wanting their bunions fixed and they have no pain.  As I am not a believer in cosmetic foot surgery, I tend to be not as understanding to the fictitious plight of this type of patient. Plus I don't think anyone ever says, "wow did you see how pretty her foot was!" But shoe gear has been shown to be a proponent of bunions and some people do have pain in their bunion.  A bunion is a deformity of the first metatarsal phalangeal joint otherwise know as your great toe joint.  The toe starts to deviate towards the little toes and the metatarsal head pushes the opposite direction, making many shoes uncomfortable.  As you can see by my stellar illustration to the right, that if you wear a
shoe that cheats a more narrow toe box you will get pain most likely in the areas I have in red.  The bone of the first metatarsal will push back on the shoe and skin causing it to get irritated.  Plus, because the big toe will be pushing to the inside the second toe it has a very good chance of being pushed up and out of the big toe's way.(see the 2nd toe bones below)  This can lead to irritation to the toe and then most likely a hammer toe over time.

Even still, with a deformity like this, shoe gear change may be the answer instead of having bunion or hammer toe surgery.  In the last 13 years of private practice at the Center for Ankle & Foot Care in Clermont, Florida I have treated many people conservatively for these problems.  I always look to a change in shoe gear first and foremost.  What kind of shoes are they wearing? Are they wearing tiny shoes like the little old lady from the ingrown nail? Are they wearing a cowboy boot? Are they wearing a shoe that is all leather with no mesh material?  Many simple tweaks to what we put on our feet can greatly improve how we function day to day with having a deformity like this.

I honestly try the conservative route first on every bunion and hammer toe patient that walks in my office.  If they are having pain or inflammation and redness to the first metatarsal head, I will have them ice and if they can be placed on an anti-inflammatory or steroid for the inflammation, I go that route first. It is only the patient that fails this therapy along with not being able to go a day without pain in the great toe joint and inability to ambulate in any shoe gear without pain, that I consider a good candidate for foot surgery.  From a stand point of patient satisfaction, these are the patients that are happy after bunion or hammer toe surgery. A bunion surgery is no walk in the park for a patient.  When we perform bunion surgery, we must cut the bone and move it in a corrected position(depending on the level of the deformity) and put a screw across it. The patient may be weight bearing as tolerated in a surgical shoe for 6-8 weeks or if their procedure is done at the base of the 1st metatarsal they may be non-weight bearing for 9-12 weeks. Pain and swelling after a bunion surgery is very common and I tell all of my bunion patients that the first two weeks are the worst.

So, again, my recommendation is that you try to change your shoe gear first before contemplating any type of surgery.

What do I recommend for shoe gear? This is a common question from patients and there is no simple answer.  If you have a bunion or hammer toe, going with a shoe that has a mesh material is always going to be superior that an all leather or pleather type shoe, mesh gives and puts less pressure on these prominent bony areas.

Saucony is a nice brand of shoes for those who need a little more room up toward the toes.  Going with this type of shoe in a mesh material reduces the irritation you can get from most shoes that are not mesh. In this type of shoe your are still getting good support of the whole foot still, which is very important.  If my patient is diabetic and suffers from hammertoes or bunions, I always recommend an extra-depth shoe and if they have any calluses on the bottom of their feet I recommend a tri-laminar inserts with offloads to decrease these areas of pressure on their feet to help avoid any ulcerations and potentially limb loss.

Keep an ear out for our next podcast, "2 Pods & a Microphone" where Dr. Henne and I will go over bunions and hammertoes and answer some questions from our listeners about shoe gear and foot surgery.  You can tune in at https://itunes.apple.com/us/podcast/2-pods-a-microphone/id909176500?mt=2 and if you want to ask us a question about this topic feel free to visit our Podcast page at
http://centeranklefootcare.com/id78.html and fill out the quick comment link, if we answer your question on the air you will receive some "2 Pods & a Microphone" swag:)

Look at your shoes, if they have no arch support ditch them or get a really good arch support like our over the counter arch supports for heel pain(shameless plug, but they are really good:) They retail for $63 and go by shoes size you can order your pair on our website   at http://centeranklefootcare.com/









Sunday, September 14, 2014

UPDATE: A. J. Green and turf toe....Foot Doctor's Fantasy Football team gone wrong!!!!



Update: today, October 8th, 2014 Dr. McGowan's Fantasy Football player A.J. Green carted off the field with toe injury we are assuming still related to turf toe.  Read our blog on Turf toe and see why a fantasy football player with turf toe is no good.

Why are we talking about turf toe and fantasy football? Well this is an injury that can greatly effect your fantasy football team.  It doesn't sound so bad, turf toe sounds like you stubbed your toe but no big deal, right? WRONG! Turf toe is an injury of the big toe joint that can be very difficult to overcome when you are propelling 300 plus pound off this little joint.  It can be the difference between being able to push through into the end zone or being stopped dead in your tracks. (FYI you do not to be playing on Astroturf to get this injury)

If your fantasy football player has turf toe and it is new, you may want to think about sitting him, especially if you have someone else comparable on your bench. This is an injury, that depending on the extent of damage to the joint and cartilage, that could seriously slow your player down. Like my A.J. Green for example, struggling for the last couple of weeks and now at practice week six  carted off the field due to his turf toe.  Which is killing me, but I hope he recovers:)

Turf toe can be from trauma to the toe in one incident or the compound effect of repetitive micro trauma over a season.  Neither one is much better. The first, a one time traumatic incident, usually is going to require some time off in a cam walking boot to rest the bottom of the great toe joint and the sesamoid apparatus.  This player will be icing and resting.  As long as the ligaments of the sesamoids are not damaged this does not have to be career ending but it will be career slowing, for lack of a better term.  If this injury is due to repetitive micro trauma over time, I believe this type of player will play but just struggle here and there.  During the off season they should go into the cam walking boot for two months to truly give it the rest it needs. 

X-rays do not show us much unless there is a sesamoid fracture involved with the injury but that is a different beast.  An MRI can be useful to see if the bones of the great toe joint are inflamed under the cartilage.  Otherwise, it truly is R.I.C.E. and time that will heal this injury, but hopefully not at the expense of your fantasy football team:) If a patient is struggling like A.J. Green it is usually 6-8 weeks in a walking cast.




Thursday, September 11, 2014

Achilles Tendon Injuries and the NFL.....Should these guys do more YOGA?




After this first week of the NFL football season, you can't help but notice the amount of Achilles tendon injuries that were reported.  In our podcast last night Dr. Henne and I discussed this topic and I said I thought maybe some of these injuries could be prevented. Dr. Henne thinks I'm crazy because I said maybe these guys should do more stretching or even yoga.  This is a very elementary way of thinking, I know, but sometimes children have the best ideas!

The Achilles tendon in the largest tendon in your body, and a part of the body we treat all the time.  For fantasy football purposes, I wanted to make this simple, as far as, that not all Achilles injury claims are created equal.  But that prevention really does come down to proper conditioning and stretching.

Insertional Achilles tendonitis is more of a chronic problem over time.  The Achilles inserts or attaches at the posterior middle third of the calcaneus or heel bone.  When the Achilles is tight, it pulls on the periosteum of the bone(I always describe this as a thin clear membrane around the bone that I liken to saran wrap).  The tendon tents up or pulls on the periosteum and this area gets inflammed and over time a bump or exostosis will form,  This is an injury the player can still play on with little risk of rupture, just mainly a lot of pain. This is also more of a chronic problem that can get better and flare up very easily.

Non-insertional Achilles tendonitis is a different beast.  These type of injuries typically take place anywhere from 2cm to 8cm above the insertion of the tendon on the heel bone.  This is commonly referred to as the "Water shed zone", a term meant to denote less blood available to this area.  So of course, if there is less blood flow getting to the area to heal a tear or strain, it takes longer for the player to get better.  This injury is usually more of an acute injury and players tend to struggle with this once they have had it throughout their career.

Both of these injuries truly stink to have, but depending on the treatment regimen the outcomes do not have to be career ending.  An Achilles tendon rupture is an injury that becomes a surgical procedure for athletes of this caliber.  Repair and recovery are not always the same from individual to individual and if your fantasy football player has an Achilles tendon rupture, or two of the main guys on your fantasy football defense have this, it's time to drop them and get someone new.  This is not an injury you come back from easily.

I have my patients with insertional and noninsertional Achilles tendonitis stretch as part of their treatment but stress to them that continuing to stretch will prevent this from coming back in the future.  I believe Achilles tendonitis, whichever kind, truly just stems from a muscle imbalance.  Our calf muscle is so much bigger than our anterior(front of the lower leg) muscle group.  They are meant to be antagonist, but the calf wins out being stronger, bigger and more powerful.  Look at your own calf and then look at these guys legs tonight.  They are huge, they need that power, but I wonder how much stretching they do to help this muscle and Achilles from doing damage to it self.

Good luck to everyone who has players tonight!


Saturday, September 6, 2014

Week One Fantasy Football Ankle & Foot Injury Report





It is Fantasy Football Season. If your fantasy football player has a foot or ankle injury, we are the experts for you. Each week will go over all the players who have lower extremity injuries and give our opinion on if they are going to play or not based on the severity and type of injury. Have a question about a particular player?  Go to our webpage: centeranklefootcare.com to fill out a quick questionnaire.

Tuesday, September 2, 2014

Is Your Pedicure Killing you?



Is your pedicure killing you?


I have to admit that I find it amusing that our last blog was titled "Are your feet at risk in the water?" and it was about shark attacks, and the word killing was not in the title of our blog or podcast.  Then we shift gears this week to, "Is your pedicure killing you?". A topic I know most women and some men do not want to hear about.  But just like many of statistics with shark attacks versus things like sink holes and dog attacks, I wanted to explore if we could put together some hard and fast, and more importantly understandable to the listener, facts that can support and maybe shift our thinking that putting our feet in the water of the nail salon may not be such a great idea!

Of course there are a thousand stories in the naked city. Everyone knows someone who has had some kind of problem after a pedicure. Dr. Henne and I see it everyday first hand. 
Anecdotally, in the last 13 years in private practice, I would say we see anywhere from 2 to 5 people daily that have fungus, infected ingrown nail or infection in the skin or soft tissue due to a pedicure. We spend time explaining to the affected, that getting a pedicure is a high risk activity and is really only a couple steps down from having unprotected sex. 

You might be thinking I have gone too far with that last comment but hear me out. Non-tuberculosis mycobacterium, Hepatitis, MRSA and many others including the very common fungal nail infection are very possible to get when sitting in the comfy nail salon chair.  I always try to comfort patients that come in with a fungal nail infection, that fungus is one of the better problems to walk away from a nail salon with. Though nail fungus is very difficult to treat, it does not typically end up with a hospital stay or potential loss of limb like some of these other problems.

One of the crusaders of informing the public about the dangers that lurk in a nail salon is
Dr. Robert Spalding Jr. As a foot doctor, Dr. Spalding is no stranger to the hidden problems of the nail salon industry and in his book, "Death by Pedicure, the dirty secrets of nail salons" he dedicates a chapter in his book to the death of two women, Kimberly Jackson and Jessica Mears, whose unfortunate deaths were after having pedicures performed.  In 2005, Kimberly Jackson, a paraplegic that was wheelchair bound due to damage of her lower extremities was unable to trim her own toenails. She sought the aid of a nail technician instead of a podiatrist for care of keeping her nails trimmed.  When Kimberly left the nail salon that day in 2005, she left with more than her toenails trimmed and painted.  She left with an open cut from the pumice stone that the nail tech had used on her foot, according her friend and neighbor, Patricia Mathis. This open cut, in addition to the soaking in the questionable spa whirlpool was the perfect storm for this unfortunate woman to develop a MRSA staph infection.  After a 7 month battle and intense medical care, Kimberly Jackson lost her battle and died.  Her cause of death was heart attack from blood infection from a staph infection from her foot.

I will now interject a story from one of the many from my own practice over the last 13 years.  About 7 years ago, a 36 year old female presented to my office with a history of a pedicure 4 days before the visit. Her past medical history, none, meaning she was healthy, on no medications and a recent physical and blood work that concurred with her very clean bill of health.  She was seen in a local nail salon in Clermont, Florida.  She was complaining of rough skin on  her foot and on her big toe near her nail.  The technician decided to use a tool, that she had used on someone else earlier in the day on my patient. The tool caused a small cut on the bottom of my patients foot and she presented 4 days after her pedicure with a swollen red and hot foot.  Her pain was excruciating, because she, unlike Kimberly Jackson, did not have neuropathy.  What this means in layman's terms, she could feel the painful presence of the bacteria eating away at her deep tissue and causing serious injury to her foot.  I explained to the patient that it would be in her best interest to be admitted to the hospital and placed on IV antibiotics and scheduled for an incision and drainage of her foot. 

An incision and drainage is a term foot and ankle surgeons use for our patients that implies that we will attempt maximal limb salvage.  In this scenario, we remove all infected dead tissue take deep cultures and leave the wound open.  We have the patient in the hospital for anywhere from 5 to 14 days depending on how the tissue looks daily. We may have to bring them back to the operating room upwards of 5 times before closing a wound. You heard me right folks, a completely healthy person could be subjected to 6 weeks of IV antibiotics, 5 am blood work daily, multiple surgeries, permanent nerve damage, functional damage to the foot, possible limb loss and death, worst case scenario, from a pedicure!

My lovely 36 year old patient, spent 2 weeks in the hospital and had 3 surgeries.  The third surgery was the final cleaning and closure of her wound.  She is someone I see now and again, at the store or for different reasons in  our small town.  She has all 10 toes and is very happy cutting and painting her own toenails. And the other woman I mentioned from Dr. Spalding's book, Jessica Mears received a pedicure on November 24, 2004 in California. She died June 20, 2005 after complications after pedicure.

If you are healthy, there is a lesson to be learned here and if you have any immune compromised illness the same lesson exists. The nail salon industry is dirty and you are putting yourself at risk not knowing all of the facts. In Dr. Spalding's book, he states that he believes that Kimberly Jackson should not have been able to have had a pedicure without a note from her doctor. I challenge that notion, as it is well documented that the nail spa industry is not clean.  Like my healthy patient, you put yourself at risk no matter what your health status may be.  If the person they used the whirlpool spa or instruments before you had an easily transferrable disease, guess what? YOU ARE NEXT!

What you need to know:
1.  Only two states currently require that a nail salon autoclave or sterilize their instruments: Texas (after poor Kimberly Jackson died) and Iowa(where Dr. Henne and I went to podiatry school, met and fell in love, but that's a different story).
2.  Shaving before a pedicure is a HUGE mistake!  Google Image the term Mycobacterium Tuberculosis feet or legs and you will never want to even soak your feet and legs in your own bath tub!
3.  I always say BEWARE of the mysterious file that a nail tech does not take out of a sterile package as well as the nail polish you have selected from the wall of colors that has been used on several clients before you.
4.  Do not always believe what you see, just because the nail technician takes nail implements from a plastic sterile looking package does not mean that those implements were sterilized.
5.  You should not let your overwhelming need to feel pretty outweigh your better judgment!

As promised in our Podcast Pictures of Credo Blade: What not to let them use on your foot during a pedicure!!!

And what Mycobacterium Tuberculosis on the legs after a pedicure looks like:

The dirty secrets of nail salons
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