This week we will focus on the types of surgical procedures used to correct for rigid and progressed bunion deformities. It is important to keep in mind when reviewing these procedures that your Podiatrists will select a procedure based on their clinical knowledge, one they deem the most appropriate and one that will provide the longest lasting results. The procedures as they are described are clear-cut, but no patient is clear-cut and decisions are also based on the patient’s subjective presentation, physical examination and radiographic evaluation.

Capsule Tendon Balance Procedures (CTB): Can be performed as a sole procedure in cases of mild deformity, but are always performed in conjunction with more corrective procedures.
• Most Common CTB: “Modified McBride Procedure”
• Indications: Mild deformity, with medial bump pain and no deep joint pain; slightly increased Intermetatarsal (IM) Angle on X-ray; minimal joint range of motion restriction
• Procedure: Dorsomedial skin incision over the hallux; release of the metatarsal-phalangeal joint (MPJ) capsule; resection/removal of the medial bone prominence; release of the adductor hallucis and flexor hallucis brevis conjoined tendon; medial capsulorrhaphy (removal of a wedge of capsule from the medial side); closure
• Complications: Hallux Varus (the opposite of HAV); recurrence of deformity; stiffness
• Recovery Period: 2 weeks in a surgical shoe; transition to a sneaker

Metatarsal Osteotomies: Procedures that make cuts into the 1st metatarsal. Some procedures make through-and-through cuts, while others remove or add a wedge of bone. All metatarsal osteotomies are performed in conjunction with a CTB, but not all CTB are performed with a metatarsal osteotomy.
• Most Common Osteotomy: “Austin”
• Indications: Mild to moderate deformity; mild increase in the IM Angle; good range of motion with no arthritic changes.
• Procedure: Dorsomedial incision; release of the MPJ capsule; release of the adductor hallucis tendon; V-cut made through the bone at a 60 degree angle; shifting of the head of the metatarsal laterally; fixation with a Kirschner wire; medial capsulorrhaphy; closure.
• Complications: Non-union; shortening of the metatarsal; fracture of the metatarsal; transfer metatarsalgia.
• Recovery Period: 4 weeks in a surgical shoe; transition to sneaker and normal activity by 8 weeks.

Phalangeal Osteotomies: Often performed in conjunction with other HAV procedures when the proximal phalanx is a contributing factor in the deformity.
• Most Common Phalangeal Osteotomy: Akin
• Indications: Depending on the location of the osteotomy cut, this procedure can be used for abnormal DASA (radiographic angle), a high hallux abductus interphalangeal angle (radiographic angle) or an abnormally long proximal phalanx.
• Procedure: Dorsomedial skin incision; release of the MPJ capsule; reflection of periosteum; osteotomy cuts made; fixation with a Kirschner wire; medial capsulorrhaphy; closure.
• Complications: Displacement of the bone fragments; stiffness; non-union; fracture.
• Recovery Period: 4 to 6 weeks in a surgical shoe.

Arthrodesis of the 1st Metatarsal-Phalangeal Joint: Fusion of the joint, which ultimately prohibits movement and eliminates pain.
• Most Common Arthrodesis: McKeever
• Indications: Hallux Rigidus/Limitus; failed previous HAV surgery; Neuromuscular disorders
• Procedure: Medial-linear incision; resection of cartilage from the base of the proximal phalanx and the head of the 1st metatarsal; fixation with Kirschner wires; joint alignment in 5-10 degrees of abduction in relation to lesser digits and 5-10 degrees of dorsiflexion off the weight-bearing surface; closure
• Complications: Poor positioning; lack of 1st toe purchase; fracture; degenerative joint disease of the proximal and distal joints.
• Recovery Period: Cast immobilization for 6 weeks with transition to a surgical shoe and eventually sneaker.

Achoo! The Common Cold of the Foot

Onychomycosis, also known as a fungal infection of the toenails, is the Common Cold of the foot, as it is easily seen 10 times per day in a Podiatrists office. It may not be the patient’s chief complaint, but it does make up about 50% of toenail related complaints that a podiatrist will see in a year. So, how does one contract it, what are signs to look for and how can it be treated?

Fungal infections of the toenails typically present as a gradual thickening and discoloration of the nails. The change in color and thickness may also be associated with a crumbly texture, noticed when the patient trims their toenails. Infection often goes unnoticed at first and will not appear on all toenails, leading patients to avoid seeking treatment until the thickening has markedly increased and they may or may not have pain with shoe wear. It is important that if you do notice such changes and suspect fungal infection, see your Podiatrist as soon as possible. The earlier the infection is identified and treated, the greater your chances of treatment success.

Most patients have difficulty understanding how they contracted toenail fungus, as they are “clean their feet and shower regularly!” Unfortunately, the fungus that infects the toenails is everywhere and often contraction of onychomycosis is luck of the draw; it is in no way a reflection of poor hygiene. It can be picked up from carpets, showers, or shoes harboring the organism. If you have had injury to the nail and expose the nail to a moist environment, you are also more likely to develop a fungal infection, as the injury provides a portal for the fungus to invade. Elderly, diabetics and men seem to have a greater predilection for onychomycosis, but it is not exclusive to them and can be seen in anyone, including children. Individuals susceptible to athlete’s foot and those who have previously been infected with toenail fungus also seem to have a greater chance of suffering.

To better decrease your chances of developing fungal toenail infections avoid re-wearing socks and do your best to keep feet clean and dry, especially after times when the foot has perspired. Do not apply moisturizers to the nails mistaking the fungus as dry skin and do not apply toenail polish in attempt to hide the color change. Both of those “treatments” tend to trap moisture into the nail and lead to an increase in growth of the fungus! It might also be helpful to carry an extra clean, dry pair of socks with you and to wear “shower-shoes” when using public showers, creating a barrier between your feet and the shower floor.

Treatment of onychomycosis can be tricky! Over the counter topicals generally are not successful, thus it is best to see your Podiatrist for treatment. Various treatment options include oral medications such as Lamisil and nail lacquers such as Penlac. Depending on the severity of infection it may be recommended that you combine a nail lacquer with an oral medication to attack the fungus systemically and topically, increasing chances of successful treatment. Other treatment options have been suggested including laser therapy, UV light therapy and several topicals that are all undergoing FDA trials. The effectiveness of these treatment methods has yet to be determined, but they do suggest promising evidence for success.

Onychomycosis is extremely difficult to treat and even after successful clearing of infection, reoccurrence rates are high. Be patient while your podiatrist works with you on an effective course of treatment!

HbA1c and Me: How does my HbA1C Level Reflect
upon my overall Diabetic Glucose Control?
- http://ping.fm/WIRcG

Hammering Out Your Hammer Toe! - http://ping.fm/vjixo

HAMMER, MALLET OR CLAW, OH MY! - http://ping.fm/K8zSJ

Should I Have My Bunion Repaired? - http://ping.fm/xpwPC

This question can be heard multiples times per week in a Podiatrists’ office, and the answer to the questions is: No, not exactly! Bunions have a variety of etiologies that can act alone or in combination with one another causing deformity of the first ray (1st metatarsal and bones of the 1st toe). Just because Mom or Pop may have a bunion, you didn’t inherit your bunions from them, you inherited their abnormal foot type.

Lets take a step backwards for a minute and talk about what exactly a bunion is. Hallux Abducto Valgus (bunion) is a triplanar, progressive deformity of the first metatarsal in which the hallux (great toe) is deviated towards the lesser toes (abducted) and rotated (valgus). HAV is one of the most common pathologies found in the lower extremity and is found in females more often than males by about a 4:1 ratio.

The most common etiology can be classified as a biomechanical abnormality: any condition whereby the 1st ray cannot function optimally in comparison to the normal or rectus foot. This encompasses a variety of pathologies including a hypermobile first ray (excessive motion of the 1st metatarsal and its articulations within the foot), inflammatory conditions of the 1st joint, neuromuscular diseases, an elevated first ray (met primus elevatus), and metatarsus adductus (medial deviation of metatarsals 2-5), to name a few. These inherited conditions prohibit the foot from functioning optimally and your body is forced to compensate for such abnormalities leading to the formation of a bunion. Thanks Mom and Dad!!

Some other less common etiologies of Hallux Abducto Valgus include post-surgical malformation, equinus (inability to dorsiflex the ankle greater than 10 degrees past neutral), limb length discrepancies, and a history of trauma to the hallux.

To prevent the occurrence of bunions, one of the predisposing conditions must be identified and corrected early on, or avoided all together. Unfortunately, this is not typically the case with inherited biomechanical abnormalities. The conditions go unnoticed or are brushed-off as something that the child will “outgrow.” Most pediatric foot abnormalities will not be outgrown and early evaluation and identification of a pathology by a Podiatrist can allow the child to be monitored and/or treated conservatively throughout their development.

Treatments options include a vast array of choices from conservative to surgical and the choice depends largely on the patients pain and discomfort in combination with a physical and clinical examination of the condition. Your Podiatrist will ask you a variety of questions to determine how fast the deformity is progressing and what methods of treatment, if any, you have previously tried. They will examine the deformity clinically to determine where the pain is localized, the degree of soft tissue involvement, the condition of the joint, the rigidity of deformity, and the underlying etiology. Your Podiatrist will also take bilateral radiographs of your feet to evaluate the joint and bone positions in comparison to “standard” radiographic angles.

Once all the pieces of the examination have been considered together, it is most likely that conservative options will be exhausted prior to surgical intervention. Conservative treatments include: injections to decrease inflammation and alleviate pain; padding of the toe to decrease pressure with shoes; physical therapy to increase the range of motion at the joint and eliminate muscular imbalances that may be a causative factor; and orthotics, which attempt to realign the foot in a more optimal position decreasing the biomechanical abnormality that may be the root etiology of your HAV.

If the deformity is rigid and severely progressed, or if conservative treatments have been exhausted without resolution of pain, surgical options become a consideration. Next week we will discuss the types of surgical procedures that may be performed in treating your bunion, the pros and cons of such surgeries and the pre-operative and post-operative courses that should be expected.

It’s no secret that your risk of injury decreases as your level of physical fitness increases. The older you get the less agile you become and the more important it is that you keep your body healthy, which includes eating right and exercising on a regular basis. Not only does a healthy lifestyle decrease your risk of injury with athletic activity, but also it decreases your risk of adult onset (Type II) diabetes, heart disease, high cholesterol…and the list goes on and on!

This guide will attempt to provide ideas for strengthening exercises to keep you going throughout the winter season. It will increase your ability to perform your best on the slopes and on the hiking trails while helping you to avoid injury. As always, it is important to consult your Primary Care Physician before engaging in any exercise routine in addition to staying hydrated and getting plenty of rest.

Cardiovascular Workout – Anything that can get your heart pumping and your body sweating constitutes as cardiovascular activity. “Cardio” workouts will increase your endurance and improve your overall strength, in addition to burning calories! Some easy and fun suggestions for this type of exercise include: walking with a friend around the neighborhood while catching up, taking your favorite “kick-boxing” class at the gym, or jogging with your dog after work. Twenty to thirty minutes, three times a week is an attainable goal.

Core Strengthening Exercises – Keeping a strong core will help increase you posture, place your center of gravity centrally in your body and improve your overall balance. Standard crunches on a mat and single or double leg-raises while lying on your back are great exercises for increasing core strength. Pikes and the use of an exercise ball for these core strengthening exercises increase the outcome, but are technically more difficult. Abdominal exercises have no minimum or maximum, so doing 3 sets of 25 in the morning and in the evening 6 days per week, will only make you stronger! For proper technique in performing the standard abdominal crunch and for other core strengthening exercises, click on the link below which will take you to a video from the MayoClinic.com (http://www.mayoclinic.com/health/abdominal-crunch/MM00725)

Thigh Strengthening Exercises – Step-ups, squats and lunges are all exercises that are great for strengthening your quadriceps, hamstrings and gluteal muscles and will help protect your knees from injury. It is important that you remember to stretch and strengthen both the anterior and the posterior muscle groups of the thigh equally. If one group overpowers the other it can lead to patello-femoral pain, which is pain in the anterior part of the knee or pain posteriorly located behind the knee. To see a video on how to properly perform these exercises, please click on the link, as it will redirect you back to the MayoClinic.com (http://www.mayoclinic.com/health/squat/MM00724)

Calf and Ankle Exercises – Increasing your calf strength and the strength of the muscles passing from the leg, across the ankle joint and into the foot will improve balance as well as decrease your risk of high-grade ankle injuries, plantar fasciitis and tendonitis among others. Simple exercises for the calf include jump-roping, single-limb heel raises with your heel hanging off the edge of a stair (3 sets of 15 reps each side), and a weighted toe raise. The weighted toe raise can be done with something as simple as a sack of potatoes hung from the mid-foot with the leg at 90 degrees and dangled over the edge of a table. Pull the toes up towards your head, hold for 3 seconds and then lower the toes back to neutral; repeat for 15 repetitions, 3 sets. Exercises for the ankle focus on stability and include a single-limb stance with the knee slightly bent held for 30-45 seconds. Balance boards, used under the instruction of a trainer can also be effective for increasing ankle stability and decreasing your risk of injury. For fun, lie on your back with one foot in the air and trace the alphabet with your foot. When you get to “z” switch to the other side.

The thigh and calf exercises can both be completed on the days in between your cardiovascular workouts, in sets of 3, 15 repetitions for each exercise. It is important that you give yourself at least one, if not two days a week for rest and recovery period so that you don’t fall victim to overuse injuries. Should you start to feel pains that feel out of proportion on one side of the body versus the other, consult your Podiatrist or Primary Care Physician for a referral and discontinue all exercise until further investigation can be completed.

As temperatures drop and snow begins to fall across the country, winter snow gear, sleds, skis, snowmobiles and ice fishing gear are being pulled from the closets. So, what is it that you need to know this winter about keeping your feet safe, warm and properly outfitted?

1. Safety: The most important thing to keep in mind is safety and not just regarding your feet, but also protecting your head. Make sure that when you head out to engage in winter fun, you dress warmly, wear your helmet and follow safety guidelines. Know the temperatures, mountain conditions, weather forecast and your abilities all before leaving the house. If you are new to the sport, it is also important that you take a lesson to ensure your safety and the safety of others.

2. Blended Wool not Cotton Socks: By design, cotton is a material that absorbs and retains moisture. With any activity, feet tend to sweat and those cotton socks you’ve been wearing won’t do anything to keep your feet dry. Wet socks lead to decreased foot temperatures and increased incidence of friction, blisters, and ulceration especially in the diabetic population. Wool has a tendency to wick away moisture, so that is a much better option over cotton. Polypropylene and other synthetic fibers also trump cotton in wicking away moisture.

3. Choosing the Right Boots: Whether your skiing, snowboarding or heading out to build a snowman with your family, you need to have boots that are designed and fitted for your sport. Make sure that when you try on a boot, it fits along the foot maintaining appropriate circulation but slightly snug so that when the boots “break-in” after several wears, they still fit. They should be properly padded around the ankle and they should never be too stiff. Finally, try boots on before you make the purchase!! It sounds ridiculous, but many patrons do not try on a pair of boots before they hand over their credit cards and are simply buying based on the style and color of the boots. This is a major no-no! Put them on, run around the store, kneel down and stress the boots as they will be stressed once you get them home. If they feel comfortable after all that, then its safe to add them to your closet.

4. Custom Foot-Beds: First and foremost, do not put custom orthotics, made for running and hiking into your ski and snowboarding boots. Your custom orthotics CAN be inserted into snow boots for shoveling and trekking to the convenient store and they CAN be transferred into your snowmobiling boots, and sledding gear. The reason they should not be inserted to skiing or snowboarding boots is that in those sports you are not moving through the traditional phases of the gait cycle. Skiing and snowboarding puts the body, legs and feet into mid-stance thus forces across the foot that occur with walking and running are completely different than those that occur during skiing. If you are having pains in the feet and/or knees with your winter activities, see your local podiatrist and bring your boots along with you. Custom orthotics can be fabricated to support your foot in mid-stance thus providing proper alignment while engaging in activity.

5. Keep in shape: Next week we will be discussing off-season and in-season strengthening exercises to keep you strong throughout the winter season. Staying in shape for the activities which you plan to engage in will keep you safe and allow you to engage up to your abilities without overshooting and injuring yourself.

1. Frostbite: Frostbite occurs when there is decreased blood flow and decreased heat delivery to the toes, but can also affect the fingers, nose and ears. Ice crystal formation takes place in the affected areas and depending on the severity of the injury can involved tendons, nerves, muscles or even bone. Symptoms include numbness, tingling, burning or loss of sensation to the area and color changes may be noted. Prognosis depends on the extent of the injury and determining this may takes weeks. In some cases amputation may be necessary or in less traumatic cases, increased prevention for reoccurrence is the only treatment. To prevent frostbite, make sure to take frequent hot-chocolate breaks from being out in the cold temperatures and investing in foot warmers to be placed between your socks and your boots will also be helpful!

2. Ankle Fractures: Ankle injuries, including sprains, strains and fractures are very common in the winter months as icy and snowy conditions lead to increased incidence of falls. According to Lauge-Hansen, an Ankle Fracture classification system, there are 4 main categories of ankle fractures classified by the position of the foot and the motion that takes place as the fracture occurs. The most common ankle fracture is classified as “Supination External Rotation” fracture (SER); meaning there is inward rotation of the ankle while the leg and body move in the opposite direction. In the most severe SER ankle fractures the tibia and fibula (bones of the leg) are broken and the ligaments surrounding the ankle are ruptured resulting in dislocation of the ankle joint. Patients suffering this type of injury will need surgical intervention to realign and stabilize the bones with internal hardware (pins and screws) in addition to repairing the ruptured ligaments. Be prepared for at least 6 to 8 weeks of complete immobilization. Preventing ankle fractures starts with wearing winter boots that have suitable traction on the bottom. Watch where you walk, and if it’s not necessary to leave the house during icy conditions, stay home and watch you’re favorite holiday movie!

3. Calcaneal (Heel) Fractures: Calcaneal fractures are less common than other type of the injury to the foot, but in the event that they do occur, they are severely debilitating. This type of injury is caused by a high impact vertical force that can occur after jumping out a window or more realistically, a fall from a ladder while hanging holiday decorations and lights! Calcaneal fractures present with severe pain and “Mondors Sign:” severe bruising of the heel that extends to both the medial (outside) and lateral (inside) areas of the foot. Due to mechanism of injury, patients often suffer associated injuries including spinal fractures. The treatment for Calcaneal fractures is much the same as that for Ankle fractures: surgical repair is necessary with the use of internal hardware and long periods of immobilization. Make sure that when you are hanging decorations this holiday season, you have a helper with you that can stabilize the ladder you’re climbing, preventing a fall.

As mentioned last week, taking preventative measures will decrease the incidence of injury, especially during the winter months. Consult your Podiatrist if you have any concerns or need suggestions for selecting appropriate “winter gear.” If you do experience a traumatic injury, get yourself to the Emergency Room as soon as possible, or call your Podiatrist for an emergency appointment.