Two posts ago we discussed tarsal tunnel syndrome. As a reminder, tarsal tunnel is the same as carpel tunnel, except for that it occurs in the feet. A nerve that provides sensation to the sole of your foot becomes compressed and trapped, causing discomfort and numbness. Let’s discuss some of the options we have to treat this condition.

The treatment of choice is based on the cause of the pain. Often, excessive pronation stretches the nerve to the point of causing tarsal tunnel symptoms. In this case, controlling the pronation could potentially help. This is done with custom orthotics made from molds of your feet taken at your podiatrist’s office. The molds are then sent off to a lab that makes orthotics that are specifically made for your feet. Once your feet get used to the inserts, the symptoms often disappear.

Tarsal tunnel can be caused by tendonitis (an inflamed tendon). In a case of tendonitis, the extra fluid around the injured tendon may be compressing the nerve in the tunnel. In this situation, the classic RICE (Rest, Ice, Compression, and Elevation) treatment may relieve symptoms. This will allow the tendon to recover and repair. In more severe cases, a small amount of corticosteroid can be injected into the area to decrease the inflammation.

If all conservative measures fail or are not indicated for your foot, surgery can be beneficial. The surgical procedure involves releasing the thick band of tissue overlying the tarsal tunnel. This relieves some of the pressure that is being put on the nerve. Often in surgery, the surgeon discovers large varicose veins or some other benign space occupying lesion (ganglion cyst, lipoma etc) inside the tarsal tunnel that are small and hard to see on MRI or other medical imaging. In these instances, the offending object is removed and surgery is very rewarding for the patient.

As mentioned before, treatment will differ depending on the cause. Work with your doctor to decide which pathway of treatment is best for your situation.

I’m sure you have heard about melanoma and its potential deadly effects. But did you know it can first appear under the toenail or the top of the foot. If unnoticed and left untreated, it can be just as fatal as melanoma found on the face or back. Let’s discuss the basics of melanoma, and then address its presentation on the foot.

Melanoma has a nice mnemonic (ABCDE) to help remind you and I how to recognize a cancerous mole before it advances too far.

“A” stands for asymmetry.

“B” stands for borders. If the borders are blurred, or not clearly defined, be suspicious.

“C” stands color. If the color of the mole is variegated, meaning different patches or streaks of irregular colors, suspect melanoma.

“D” stands for diameter. Most melanomas are at least 6mm wide, or about the size of the eraser on a pencil.

“E” stands for both elevated and evolving. You will always be able to both see and feel a melanoma because it will be elevated above the skin. Evolving means that a cancerous mole is always changing (i.e. getting bigger, changing color, becoming easier to feel). If a mole looks the same as it did 10 years ago, it probably isn’t melanoma.

Now that we know what to look for, it is important to remember that there are different types of melanoma. There is a type that seems to present more often on the palms of the hands and soles of the feet, including under the nails. How can you tell the difference between a blood blister under the nail and melanoma? A blood blister will grow out as the nail grows. If it is a melanoma, the discoloration stays in the same spot.

Your podiatrist can help you determine if a new discoloration under the toenails is something to worry about. He/she will be able to work with your primary care or dermatologist to treat the melanoma before if progresses.

Almost everyone has heard of Carpal Tunnel Syndrome. With the advent and widespread use of the computer over the last 20 years, carpel tunnel has become more common than ever before. Carpal Tunnel Syndrome occurs when a nerve from the arm becomes compressed and irritated as it attempts to pass into the hand through a very small tunnel in the wrist. This causes numbness and discomfort in the hand, and if left untreated can cause permanent damage to the muscles in the hand.

Did you know there is a similar condition that exists in the feet? Similar to the hand, a nerve passes from the leg to the foot via a tunnel on the inside of the ankle. The contents of this tunnel include muscle tendons, a large artery, and veins. If anything within that tunnel becomes inflamed and enlarged (for example a varicose vein, or an inflamed tendon with extra fluid around it), the nerve within the tunnel will be entrapped and compressed. This condition is called Tarsal Tunnel Syndrome. Although there are many causes of this condition, the most common cause has to do with the mechanics of the way you walk.

Symptoms of this condition are very similar to that seen in the hand. The nerve compressed in tarsal tunnel gives sensation to the entire sole of the foot. Therefore, if Taral Tunnel Syndrome is present, you should feel a pins and needles, numbness, or shooting and burning sensations everywhere on the bottom of the foot. This pain may worsen with prolonged activity such as running or walking. In extreme situations, the pain may wake you up at night. If left untreated, the muscles in the foot may atrophy and cause hammertoes and other pressure points.

Tarsal tunnel can usually be treated by conservative measures, but without resolution, there are surgical options that exist to help decompress that area. We will discuss them in the next post.

Pronation is a word that I am sure you have heard at the podiatrist’s office and elsewhere in the foot and ankle world. You may even come across it when buying shoes or over the counter insoles. If you are an avid runner, you can find it used extensively in running magazines and other publications. Some say pronation is bad, or that you can “over pronate.” But what does it really mean?

An incredible amount of force is directed on your heel bone and foot joints while walking and running. Pronation is your body’s way of absorbing that force as you walk. There is a joint just below the ankle that moves in a way so that when you take a step, the foot is more mobile so it can adapt to the uneven surface that we are walking on. In podiatry, we say that your foot becomes a “loose bag of bones” or that it pronates. This allows the force to be shared equally across the foot and it spares our cartilage from being over stressed. In short, pronation is a good thing.

But just like anything else, too much of a good thing is bad. Once you have taken a step and your weight moves forward, you want to be able to push off that foot and propel yourself. At this point, you want your foot to be stiff and stable (or as we say in podiatry, in a supinated position). However, if your foot is still a “loose bag of bones,” meaning you pronate too much or for too long, you have nothing stable to push off of. This is one reason why some people develop bunions, hammertoes, plantar fasciitis etc… You are pushing off of an unstable foot and the bones start to move in every direction, causing deformities. It would be similar to trying to hammer in a nail using a waffle. The waffle will twist and bend in every direction with nothing being accomplished.

The mechanics of feet are much more complex than the explanation I have given, but hopefully it will help you better understand how you walk.

During an acute gouty attack, the pain can be incredibly exquisite. Immediate treatment is needed to relieve the discomfort. Indomethacin is a stronger version of aspirin used to decrease the inflammation occurring in the big toe joint. This can be taken at the onset of pain and usually can decrease the pain within a couple hours. Once the pain has subsided, the drug should be discontinued due to its blood thinning effects.

Another drug that be taken on the onset of pain is colchicine. Colchicine, similar to indomethacin, will decrease the activity of the immune system within the joint, thus relieving the pain. Colchicine is most effective when it is taken within 24 hours of the onset of pain. Once the pain has subsided, colchicine (at a lower dose) can be taken to protect against gout attacks in the future. Colchicine is a strong drug that can cause nausea and vomiting, so it must be taken with caution.

While indomethacin and colchicine help with the pain, they do not address the root cause of the pain. Work with your rheumatologist to figure out if you are over producing uric acid, or not excreting enough of it. Additional treatments are available to address the origin of pain. Uloric is a newer drug that is showing promising results.

As mentioned before, consumption of foods like beer, steak, and other high protein diets can cause a spike in uric acid that can lead to gout. Avoiding these foods altogether, or minimizing the amount consumed at any given time can help to decrease uric acid levels.

If attacks become uncontrollable, there may be extensive damage to the cartilage in the joint and unrelenting pain. At this point, you may want to consider surgical options that would get rid of the pain permanently. A joint fusion is a procedure that you may consider to find relief. Discuss these options with your foot and ankle surgeon.

It was New Year’s Eve, so you went out, ate a nice juicy filet mignon, and drank a little more than you planned. Now it’s New Year’s Day, you wake up and your big toe joint is red, hot, and swollen. The pain is getting worse as the day goes on. The pain is so bad that it even hurts to have a bed sheet touching your foot. How did this happen? How did it develop so fast? What can be done?

Gout is a condition in which uric acid builds up and crystallizes in the joints of the body. The crystals damage the cartilage in joints and make movement very painful. Uric acid results from the breakdown of purines, a substance found in high protein foods like beef, seafood, and beans. Purines are also high in certain types of alcohol, especially beer. Uric acid is normally removed from the blood by the kidneys, but if overloaded, uric acid will find other places to deposit in the body. Uric acid crystals form easier in lower temperatures, so it chooses the feet, hands, and ears since those are the cooler parts of the body. The first gout attack usually happens in the big toe joint, but it can happen at other joints. The pain is the worst during the first 24 hours of the attack, and slowly subsides during the coming days. An attack can happen even if your current blood uric acid levels are low, so levels must always be watched.

Historically, this was known as a diease of the rich, since only the rich had enough meat to trigger a gouty attack. Now that we know the source of the pain, most people can manage their gout with medications and diet modifications. We’ll discuss those options next post.

Chronic ulceration has been an ever increasing problem with the rise of diabetes. As time has gone on, new techniques have been developed in an effort to help ulcers heal faster and more definitively. Some techniques have lost favor in practice, while others have become standard of care. One technique has changed how we treat ulcers, and it may surprise you where this product comes from. Let’s define a few terms first.

An autograft is taking tissue from one part of the body and using it somewhere else on the same person. An example of an autograft would be taking a vein from your leg to use in the heart in bypass surgery, or taking skin from the buttock to cover a burn or ulcer. An allograft is taking living tissue from one human being and using it in on another human being. This is the principle currently being used to help heal chronic non-healing ulcers.

Dermagraft and Apligraft are examples of autografts that have been developed to help close diabetic ulcers. These two products are derived from neonatal foreskin. Yep, that’s right… we’ve taken the skin after circumcision and put it together with growth factors to make it grow. The skin is then cut into smaller squares, packaged, and sent refrigerated so that it can be used in offices across the country. These grafts contain living cells on a “scaffold” that can integrate with the patient’s skin. Studies of these products have shown that increase the likelihood of an ulcer healing.

These products are not cheap, but because of their incredible performance in helping diabetic patients, many insurances including Medicare cover anywhere up to six applications of this products. Your podiatrist can help you understand more about these treatments.

So you had an ulcer that you thought had closed up, but every time you visit the podiatrist, he takes a scalpel to your foot and opens the ulcer back up. Why does he do that? Before I answer, let’s talk about three things that an ulcer needs to heal: Offloading, Blood Flow, and Decreased Bacterial Load.

Offloading means taking precautions to insure no weight is being put on the ulcer. This means altering shoe wear or even totally immobilizing the foot with the ulcer. If safety measures are not taken to avoid walking on the ulcer, the friction and sheer forces will not allow a diabetic’s delicate skin to heal over the ulcer.

Blood flow is the key to all healing. It contains the growth factors and oxygen needed for the skin to grow over and close the ulcer. In an effort to close the wound, the body will lay down fibrotic tissue. The wound then becomes “senescent” or asleep, meaning the body forgets that it’s there and stops sending blood and healing factors to it.

Bacteria is naturally found on our bodies, but it can’t penetrate intact skin. Once an ulcer opens up, bacteria can enter and produce substances that stop healing. Bacteria can even enter the blood stream and cause additional problems elsewhere.

Now, you were wondering why the podiatrist cuts you up when you come in. By removing the yellow, fibrotic tissue, we “wake up” the body, reminding it that a wound is there so it continues to send healing factors. We like to cut so that we see bleeding, pink tissue so that we know blood is reaching the wound. Bacteria like to grow on the fibrotic tissue, so by removing it, we decrease the bacteria load on the wound. And lastly, you are less likely to walk on a bleeding wound compared to a wound that looks healed over. By following these guidelines, the healing time of an ulcer is much faster.

We have discussed in this blog the many issues a diabetic may face in maintaining their health. Neuropathy, or loss of sensation, is a major contributor to the development of pain and diabetic ulcers. What can be done to battle this problem? Let’s discuss.

First and foremost, a person with diabetes must look at their feet frequently. Their eyes need to become surrogate nerves for their feet. By performing a daily inspection of the soles of their feet, in between the toes, and on top, they are more apt to finding a developing ulcer sooner. If it is too difficult to inspect their feet themselves, have a family member do it, or place a mirror somewhere it can be used to see the feet.

Another important tool that can be used is a temperature gauge like the TempTouch. An ulcer usually occurs because of excess pressure and friction on a certain spot on the foot. These rubbing forces create heat. By using a device that can measure the temperature of the skin, you can get an idea of where the pressure and friction are concentrated before an ulcer occurs i.e. the hot spots. You can then take measures to off-load or add extra padding to that part of the foot. This type of temperature gauge can help alert you before an ulcer occurs, and it costs about the same as a month’s worth of neuropathy medication.

Lastly, there have been some recent advances in pharmaceutical treatment of neuropathy. Lyrica and Cymbalta are two newer drugs that have been very effective. In the past, neuropathy medications required you to take them three times a day and you needed to slowly build up the levels in your body to avoid side effects. Both Cymbalta and Lyrica are taken once a day, do not require slow introduction, have very minimal side effects, and provide relief sooner.

November is Diabetes Awareness month, and in that spirit, I wanted to discuss some of the reasons why diabetics face the challenges that they do. The three subjects that diabetics commonly wrestle with are neuropathy, immunopathy, and vasculopathy. All three are tied to the excess blood sugar present in a diabetic patient.

Neuropathy is a term meaning malfunctioning nerves. As mentioned before, a diabetic patients blood sugar is not as tightly controlled as a non-diabetic. Often the excess sugar will begin to deposit in places it is not normally found, like a nerve. Sugar is osmotically active, meaning that sugar will attract water to it. When sugar draws excess water to a nerve, the nerve begins to swell and be compressed against surrounding tissue. This can cause numbness, or a low aching pain, especially in the legs and feet. When nerves stop functioning, a person loses the ability to sense pain. This lack of sensation may be so blatant that a diabetic could step on a nail and not feel a thing.

Immunopathy is a term meaning a malfunctioning immune system. White blood cells are the cells that protect the body from bacteria and other infections. They help the heal cuts and scrapes we get normally. But just like before, high blood sugar causes white blood cells to malfunction. Instead of wounds healing fast and clean, non-healing ulcers can form. These ulcers can act as entry points for bacteria into the body.

Vasculopathy is a term meaning malfunctioning arteries and veins. It has been shown that diabetic arteries tend to harden and become narrowed very fast. So in addition to not feeling pain when an injury happens and white blood cells not healing the injury, diabetics have decreased blood flow to the legs and feet, thus decreasing the chance of healing an injury.

If not cared for quickly, a non-healing wound on the legs or feet may set the stage for amputation. It is imperative for diabetic patients to routinely see a podiatrist. Their feet will thank them.