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.

We’ll return to the skin discussion soon, but I’ve seen two cases of a relatively rare neurological disease walk in the door in the last week, so I thought it would be worth it to talk about it.

Charcot Marie Tooth is a disease that affects the myelin sheaths that cover the nerves in the body. If we think of a nerve as being an electric wire transmitting signals, myelin is like the insulation around the wire to make the signal travel faster to its destination. It is precisely a defect in the myelin that causes the signals that the brain sends out to be slower and inconsistent.

The nerves that have to travel the farthest are usually the first to be effected in Charcot Marie Tooth. Therefore, the small muscles in the feet and legs tend to show the first signs of the disease. Because these muscles are not being stimulated in a normal fashion, they begin to get smaller and tighten up. The calf muscles get so small that patient’s legs have been compared to “stork legs” or “upside down champagne bottles.” The tightening causes the toes to permanently curl up, the arch to be extremely high, and the Achilles tendon to be so tight that you can only walk on the ball of the foot. As you can imagine, this makes it very difficult to keep your balance when walking.

The disease is progressive, meaning that it starts without any obvious warning, and it worsens year after year. Due to its slow onset and progressive nature, someone can go years without being diagnosed. It will become more and more difficult to walk and the pressure on the forefoot can be so dramatic that deep calluses and even ulcerations can form on the ball of the foot. As the disease progresses, the hand muscles can become involved.

If there is a bright side to this condition, it is that it does not affect a person’s ability to think or their memory. Their lifespan is expected to be normal. However, if gone untreated for decades, it may confine a person to a wheelchair. We’ll discuss next week how to detect the early signs of the disease, the diagnostic tests that can help, and the treatments available.

Now that we understand how to recognize stasis dermatitis, let’s discuss what can be done to treat the problem.
Unfortunately, it is impossible to repair the old valves in our veins. However, we can try to compensate for their malfunction by trying to make their job easier. This is done by elevating the legs above the heart when sleeping or lying down. This allows gravity to move the fluid back to the heart. There are even leg pumps that you can use to mechanically massage the leg and move the fluid back into circulation.

Obviously, it is not always possible to keep the legs above the heart. For these instances, a person can wear compressive stockings that help to put pressure on the lower leg and foot so as to minimize the space fluid can collect. These can be worn all day long, or even during air travel to keep blood from pooling in the legs and feet.

One word of caution… Patients who have heart conditions may need to check with their cardiologist before they engage in increasing the fluid flow back to the heart. If the heart cannot handle the extra fluid, they may put themselves into heart failure. It is better to have some swollen ankles than overloading the heart with an amount work that it cannot handle.

As mentioned before, stasis dermatitis can also cause the legs to become very itchy and uncomfortable. Topical corticosteroid cream can be used to combat this discomfort. But again, be judicious with this cream as it may cause the skin to become very thin and fragile.

If treated correctly, venous ulcers can be avoided. Work with your podiatrist in management of your condition to get the best outcome.

It is important to understand the adverse effects of smoking tobacco in regards to the recovery and outcome of a surgical procedure. Smoking tobacco introduces three main substances that may lead to a longer recovery or undesired outcome.

1. Nicotene – Nicotene constricts blood vessels, leading to decreased blood flow

2. Carbon Monoxide – Carbon Monoxide decreases the amount of oxygen your blood can carry

3. Hydrogen Cyanide – Cyanide decreases your cell’s ability to make energy to repair itself.

When combined together, these substances substantially slow the healing process and allow complications to occur. Patients who continue to smoke prior to and after surgery have increased risk of their surgical wound opening back up, leading to infection and slowed healing of the bone and skin.

Although complete cessation of smoking would be the ideal approach, this often is not a realistic option.

However, if a patient managed to stop smoking a couple weeks before surgery, and maintained that during the recovery period, the healing of skin and bone would be dramatically increased. When it comes to bone and skin healing, ceasing to smoke can have immediate benefits. Although the long term effects of smoking remain, removal of nicotine and carbon monoxide will intensely improve the flow of oxygen to the tissues. Even if a patient only was able to stop smoking for a few days before and after, studies show patients are more likely to heal faster without complication than patients who continued to smoke.

In you are currently preparing to undergo a foot or ankle surgical procedure, please carefully consider the benefits of avoiding smoking leading up to your surgery date. If you have any concerns or questions, feel free to discuss them with your podiatrist during your next office visit.

Let’s revisit our discussion on dermatitis. So far, the forms of dermatitis that we have discussed had to do with a substance irritating the surface of the skin. But it is important to remember that there are internal factors that can cause dermatitis.

Stasis dermatitis is a form of skin irritation that results from problems with blood flow, especially on the lower leg. Under normal circumstances, blood flows away from the heart in arteries, unloads the oxygen it carries to body organs and tissues, then ending its journey by flowing back to the heart in veins. In order to prevent backflow of blood, veins have valves that make sure to keep blood flowing in the correct direction.

With stasis dermatitis, the valves in veins can malfunction and lose their ability to direct blood flow. Instead of being directed back to the heart, the blood pools and sits in the veins in the foot and lower leg. The veins begin to expand as the volume of blood within them increases. This leads to increased pressure inside the veins, pushing fluid out into the skin, giving the lower leg a swollen appearance. In addition, some of the pooling red blood cells can break down and cause the overlying skin to be discolored. The skin can become itchy, and it may cause people to have night cramping.

Probably the most serious complication of this condition is called a stasis ulcer. Unlike other ulcers, this sore is not due to friction or trauma. It is thought that the overlying skin is starved of adequate oxygen, causing the skin to die and form a very painful ulcer. To make matters worse, the ulcer usually does not heal quickly and can be an entry point for infectious bacteria into the body.

Luckily, podiatrists have become specialists in this arena of medicine. There are many potential treatments available that have shown to be beneficial. We’ll discuss treatment options in our next blog post.

We’ve been talking about skin problems the last couple weeks, and we will return to that subject next week. But this week something happened that has convinced me to discuss something else.

The Philadelphia Phillies are a baseball team that was expected to reach the World Series this year. However, they were on the brink of being eliminated from the playoffs by the St. Louis Cardinals this last week. Ryan Howard, the 1st baseman for the Phillies was Philadelphia’s last hope. Unfortunately, he made the last out to end the game. To make matters worse, as Howard tried to run to first base, he fell to the ground in pain. Once evaluated, it was apparent that he had ruptured his Achilles tendon.

Achilles tendon ruptures are common and often happen with abrupt pivoting movements or when someone starts exercising after a long period of inactivity. When it happens, the person describes the event as if they were hit in the back of their heel with a bat and they hear an audible pop. Incredibly, they will still be able to walk, but with dramatic difficulty. If you run your finger up the back of the heel, you’ll feel a depression or soft spot instead of the normal tense tendon inserting into the heel. Some ruptures are partial while others may be complete. If the rupture is bad enough, the tendon can recoil on itself like a fruit rollup.

If you try to treat a rupture conservatively, the recovery time is longer and the risk for re-rupture is very high. For that reason, ruptures are most effectively treated with surgical repair. Although you take on the risks of surgery, surgical repairs allow for better results long term. You often can resume exercise sooner, the motion in the ankle is better, and overall the patients have fewer complaints. Your podiatrist is a skilled surgeon that can perform this surgery and help you along your road to recovery.