Over the last two weeks we’ve been discussing diabetic complications of the lower extremities; an important topic in terms of raising awareness and helping you to prevent or slow progression of such complications.  This week, I want to focus on the function of the foot in the diabetic population and again, how prevention is your best option for decreasing your long-term risk of complications.

In the diabetic population, equinus is the overwhelming commonality between patients suffering from plantar wounds associated with diabetic neuropathy.  Equinus, to explain it simply, is a lack of dorsiflexion, or ability to raise the foot at the ankle joint past 90 degrees (neutral position).  The ankle and foot function best in gait when dorsiflexion at the ankle is at least 10 degrees past the neutral position.  When this is decreased, excess pressure is placed on the plantar forefoot throughout gait, and increased pressures automatically lead to an increased risk in ulceration.

Patients develop equinus from a lack of flexibility in the musculature of the leg, namely the calf.  Whereby, dorsiflexion becomes decreased because it is those muscles in the calf that are responsible for lifting the foot above that neutral position during gait.  If those muscles are tight or contracted, which occurs in patients who don’t stretch or exercise on a regular basis, equinus and increased forefoot pressures result.

Increased pressures in any area of the foot create a major risk in the diabetic patient, and such pressures can also be induced by tight fitting shoes, open-toed sandals that rub between the toes, and areas of friction along bunion prominences or on the tops of contracted digits (hammertoes) in closed-toed shoes.  The reason increased pressures are such a risk is that in places of friction, typically not felt by the neuropathic diabetic patient, a pre-ulcerative lesion may develop.  The area goes undetected, unless you’re religiously checking your feet on a daily basis for new lesions (which you should be doing!), and the pre-ulcerative lesion turns into a wound.

Again, you are faced with the issue of non-healing secondary to poor circulation (which we discussed last week), such that the nutrients needed for wound healing carried by the blood have difficulty getting to the area.  In addition, if you have not addressed the issue of equinus or the problem shoes that created the initial friction, you’re bound to have problems in the future, even if you’re able to heal this time around.  So what can you do? Again, the answer is prevention!

There are two important ways in which you can take control of the deforming forces of equinus and increased pressures placed on the foot:

1. Stretch – By stretching the musculature in your calf and increasing the flexibility around the ankle joint (decreasing your equinus), you will greatly decrease pressure placed on the plantar forefoot and decrease your risk of ulceration.  There are several exercise, that are easy to do:
   1. Wall Stretch:  With your feet shoulder width apart, one foot in front of the other, place your hands on the wall in front of you.  Keeping the back leg straight and the front leg bent slightly at the knee, lean into the wall.  You should feel a light stretch in the calf of the straight leg.  Hold this for 20-30 seconds, take a 15 second break and repeat 10 times.  Then switch front and back feet, so that you can stretch the opposite side.  Again, hold for 20-30 seconds, repeating 10 times.
   2. Heel Drop:  This exercise will require a set of stairs with a railing available for balance.  Place the balls of both feet on the step, knees straight and allow the heels to suspend off the step and drop down below the level surface via your body weight.  You should feel a light stretch in the calf of both legs.  Hold this for 20-30 seconds, take a 15 second break and repeat 10 times.
2. Invest in a pair of diabetic shoes – Especially important for those patients with diabetic neuropathy, but important for any diabetic patient.  Diabetic shoes have a custom molded insert with a wide and deep toe box.  The insert is made from a mold of your foot and alleviates all areas of pressure on the plantar foot.  The wide and deep toe box allows the foot room within the shoe, preventing areas of friction on boney prominences.  Diabetic shoes essentially alleviate all friction areas, thus decreasing your risk of pre-ulcerative areas and ultimately of developing an open wound.

As you can see, the power again remains in your hands when it comes to decreasing your risk of complications associated with diabetes!  With diet and exercise, controlling your blood glucose levels, managing your co-morbidities and preventing areas of pressure in the foot, you’ll be well on your way.

Patient’s recently diagnosed with diabetes are often encouraged to visit a Podiatrist for a complete lower extremity exam, but the reason for this evaluation is unknown to the patient! Podiatrists have expert knowledge in understanding the lower extremity in addition to the affects that diabetes can take on the body, and we will evaluate you and identify risk factors for increased complications in the short and long-term. As we discussed last week, diabetes is an autoimmune disease that stimulates an increase in blood sugar levels if not managed correctly. The first complication we see in the diabetic population, relative to the lower extremity, is a loss of sensation in the feet, or diabetic neuropathy. In last weeks blog, we mentioned that prevention is most important in managing this complication, and this same ideal goes with this weeks discussion on circulation to the lower extremities in the diabetic patient.

When it comes to circulation, the complications that present themselves to anyone, but especially the diabetic patient with diabetic induced neuropathy becomes the decreased flow, and subsequently decreased healing potential in the lower extremities. The circulatory system in our bodies, beginning with the heart, carries blood, oxygen and thousands of growth factors out to the organs of our body supplying nutrition to those areas. When blood flow out to the extremities decreases, as it often does in the diabetic population, healing potential deceases because those nutrients can longer reach the affected areas. Thus, with neuropathy, if an injury to the soles of the feet goes unnoticed and blood flow to that area is compromised, healing to the site of injury becomes very difficult!

Decreased circulation in the diabetic patient comes from the root of all evils: uncontrolled blood sugar levels. Long-term, uncontrolled blood glucose levels induce damage on the arteries of the body, particular the peripheral arteries (those farthest from the heart) through weakening of the vessel walls. Weakening creates strain on the vessels and often leads to their thickening or collapsing in efforts to overcome that strain. In addition, co-morbidities often seen in the diabetic patient, including high blood pressure and high cholesterol, increase damaging risks to the vessels. These other medical issues induce atherosclerosis, which is a fancy way of saying “narrowing and hardening” of the vessel walls, making it more difficult for blood to flow easily down to the feet.

At your Podiatric appointment, in addition to checking the sensation in your lower extremities, your circulation will be evaluated. If pulses are easily palpable and there are no open wounds, at that point in time you’re good to go! However, if the pulses are difficult to feel, if your feet are a little cooler than your legs and if blood flow into the toes is slowed, it will be explained to you that circulatory issues are presenting themselves. It may be that your Podiatrist will order lower extremity arterial (blood flow) studies to evaluate your flow in addition to evaluating your healing potential so that a baseline of your circulatory status can be noted. It certainly isn’t the end-all, be-all to have circulatory issues, but it simply means that you need to be more careful and as we discussed in relation to diabetic neuropathy, prevention of further circulatory issues is the best possible scenario!

The ways in which you can prevent circulatory complications are many, but first and foremost include controlling your blood glucose levels to prevent weakening of the peripheral arteries. Next, you can decrease your risks by following up with your primary care physician regularly for management of your co-morbidities such as your high blood pressure and high cholesterol. Take medications prescribed to you as directed to lower the risk of complications by these associated medical issues. In addition, maintaining a good exercise routine, even if its 30 minutes of walking three times per week, helps increase blood flow and efficiency of the heart. (Of course, speak with your doctor before starting any exercise routine.) Finally, protect your feet! Wear shoes at all times and check the soles of your feet and in between your toes daily. Catching an opening in the skin early on significantly increases your chance of healing that wound, as the longer it goes unnoticed, the longer it will take to heal.

Next week, we will discuss the biomechanics of the feet, relative to diabetes and what you can do to decrease pressure areas that lend themselves to ulceration!

It’s been quite a while since we tackled the topic of Diabetes, and because understanding the disease and the complications it can induce throughout the body and especially your lower extremities are so important, I want to refresh your memory. Over the next few weeks we will discuss in detail the complications seen in lower extremities and what you can do to help yourself avoid or manage these.

Diabetes is an autoimmune disease that affects the levels of glucose (sugar) in your blood. In patients with diabetes, they either don’t produce enough insulin to breakdown their daily calories, or they make no insulin at all. Whichever type of Diabetes you have, either type can lead to complications in the lower extremities.

The first complication we typically see in the diabetic population is loss of sensation on the plantar aspects of their feet, also known as Diabetic Neuropathy. High glucose levels in the blood stream tend to induce changes around the nerve coverings beginning first with the hands and feet. For our purposes, it’s best to explain this as sugar molecules that grab on to the nerves in the feet and decrease their function: known as glycosylation within the medical community. There’s good news and bad news in relation to glycosylation. The good news: in the beginning stages glycosylation is reversible – yay! The bad news: glycosylation can lead to detrimental insults to the plantar aspects of your feet and eventually your legs, working its way towards the center of the body.

The first step in understanding Diabetic Neuroapathy or glycosylation of the nerves begins with understanding the symptoms. Do you ever experience numbness or tingling in your feet? Think of it as the “pins and needles” you would feel if your foot fell asleep. Do you ever experience a “burning” type pain similar to when you hit your “funny bone?” These are both early signs of nerve changes in the feet and if not detected early on, their ability to be reversed is lost.

These feelings are a sign that the glucose levels in your blood stream are too high, and better diabetic blood sugar control is necessary on your part. Whether that means changing your diet, increasing your medications etc, to lower your blood glucose level, you need to take action. Taking such measures will help to decrease the effects of glycosylation and some sensation may return. However, once the glycosylation is too far along, these simple measures will no longer be helpful! Thus early detection is important, but prevention is key! Managing your blood glucose levels from day #1 of being diagnosed with diabetes will prevent and slow progression and development of sensation complications.

The effects that loss of sensation has on your feet are great! Once you have lost the ability to feel, you’ve also lost the ability to know that you’ve stepped on something and that you now have a wound or ulceration on the plantar aspect of your foot. When you don’t realize this, you don’t realize that treatment may be necessary, the area gets dirty, gets infected and leads to, in the worst-case scenario, infected bone and loss of toes.

If you’ve reached the point where Diabetic Neuropathy has affected you, there are still things that you can do to prevent ulceration and infection. It’s as simple as checking your feet daily. So, what should you look for? You should look for any changes since yesterday on the bottoms of your feet, around your ankles and in between your toes. By checking daily, you’ll notice any small differences immediately, even if you can’t feel them, and get treatment at the get-go. In addition, there are medications available that your Podiatric Physician can prescribe to help control the symptoms (burning, numbness, tingling) but none of these medications will restore feeling.

Don’t wait until the early signs of Diabetic Neuropathy set-in; control your blood sugar levels today and help prevent this complication for tomorrow!

Although drinking alcohol or eating “trigger” foods such as seafood sometimes induces gouty attacks, it’s not always the case! Gout can be triggered by various other factors including injury, infection, and crash diets – an attack may not always depend on what you’ve eaten, however it is always related to the levels of uric acid in the blood.

Gout is a form of arthritis that can be extremely painful in its most acute state when patients are suffering from a flare. It falls into the category of arthridities because when uric acid levels are high gouty crystals settle in joint spaces, typically the big toes or the elbows, and induce boney changes, ultimately affecting the function of the joint. There may be a genetic link, but post-menopausal women and men between the ages of 40 and 50 are more likely to suffer from gout. Children are rarely affected.

High uric acid levels do not cause symptoms in every individual; some patients are able to handle high levels and never develop symptoms, nor do they develop flares. However, in patients with a predisposition, for whatever reason, high levels of uric acid (greater thank 6.0 mg/dL) induce pain, inflammation, warmth and redness around the affected joint(s). The pain comes on suddenly and can be so severe that even bed sheets cause a discomfort! Often times, crepitus (the sound of rice crispies) can be heard and felt when the joint is mobilized. Crepitus is the movement of the uric acid crystals within and around the joint!

At the first sign of a gouty attack in the lower extremity, you should seek treatment from your Podiatrist rather than suffer through the pain. To help confirm your diagnosis they may want to send you for blood work to measure the uric acid levels in your blood in addition to taking a sample of fluid from the affected joint. Your Podiatrist may also take x-rays of the affected toe joints, as uric acid deposits can be seen on plain x-rays.

In addition to using such diagnostic tools, gout provides a very distinct clinical presentation and it is very likely that your Podiatrist will immediately try to treat your flare and decrease your discomfort. There are a variety of options that can help decrease an acute attack including a steroid injection into the joint and/or an oral anti-inflammatory medication, such as Indomethacin, to decrease inflammation and subsequent pain. Immediate treatment, in addition to decreasing symptoms, can also help decrease the long-term affects on the involved joint(s). Once the initial attack has been treated and uric acid levels return to normal, preventative medications are not necessary for one-time sufferers.

However, patients who have suffered from multiple gouty attacks and are predisposed to flares may be given a medication to take daily. Your Podiatrist will determine the best medication for your long-term control based on whether you are an “over-producer” of uric acid or an “under-excreter” of uric acid. The idea behind a daily medication is to maintain “normal” levels of uric acid in the body, thus lowering your risk of subsequent gouty attacks. It’s important to keep in mind that even at times when you’re not experiencing a flare, uric acid levels may still be elevated in the body, and joint damage can still take place!

As mentioned, the food you eat may not contribute to a gouty attack, but it can! Gout used to be known as the “Disease of Kings” because of its association with rich foods that Kings typically had access too. Foods that are high in purine (the chemical responsible for producing uric acid in the body), such as red meat, seafood, spinach, alcohol, mushrooms, and oatmeal, to name a few, should be kept to a minimum in patients predisposed to gout or gouty attacks. Gout has also been linked to medical conditions such as hypertension (high blood pressure), diabetes, hyperlipidemia (high cholesterol) and atherosclerosis (narrowing of the blood vessels), so it is important to manage your co-morbidities with your primary care physician in addition to keeping a good watch on your diet to limit your flares!

The answer to question “how many legs does a spider have?” is eight! However, the answer really doesn’t matter, as the most important question should really be: which leg did the spider bite? Spider bites, although not extremely common in the United States, do happen, and if you know the signs and symptoms, you will be one step ahead in the treatment process.

There are two spiders in the United States that one should be worried about: the Black Widow spider and the Brown Recluse spider. The more “deadly” of the two is the Black Widow spider, which can be identified by its black color and distinct red hourglass-shaped marking it bares on its underside. Unless you notice this spider on your skin, you may not know that you’ve been bitten, as the bite only feels like a pinprick. However, within the next several hours, you will realize that you’ve been bitten by something, as the area will swell and be accompanied by intense pain and redness. If you seek treatment, as most patients do once they notice symptoms, the bite of the Black Widow is rarely lethal.

The Brown Recluse spider also has a distinctive marking on its back that identifies it: a violin shaped marking. This spider is generally less lethal than the Black Widow, but does have severe side effects. The bite initially stings and one may notice mild redness at the site with increasing pain as time passes. Eventually, within eight hours, a fluid-filled blister will develop on the skin and remain for several days. The blister will subside, draining itself of its fluid, revealing a large burrowing ulceration that goes straight through the layers of your skin, down to bone. Aside from the burrowing ulcer the systemic symptoms (symptoms felt in various organs systems) include fever, rash, nausea, vomiting and intense fatigue.

As mentioned, knowing that you’ve been bitten by a spider, and even better, identifying the type of spider that it was, puts you ahead in the treatment process. As soon as you notice the bite, wash the area with soap and cool water. This will wash away any toxin that may be left behind on the skin from the time during which the spider was on your body. Cold compresses should also be applied, as they will help to decrease the inflammation and redness around the area. Of course, Tylenol or anti-histamines (such as Benadryl) can be taken to decrease pain and skin reaction or rash, however, keep track of what you’ve taken, so that if you seek medical attention, you can relay that information to the physician. If you experience swelling or vomiting with an associated fever, seek medical attention immediately. It may be that you require “anti-venom;” a medication that will counteract the bite of the Black Widow spider. If you’ve been bitten by a Brown Recluse spider, local medications, applied to the affected area, are usually sufficient for treatment.

As Podiatrists, Brown Recluse bites are the spider bites that we see most commonly. The reason being, that the side effect of their bite, is the burrowing ulcer. If on the foot or leg, a Podiatrist is fully qualified to treat the area with local wound care, applying wound products and dressings that will encourage the defect to fill in and eventually return your skin to normal over the course of several weeks. As a specialty, we are trained and qualified in wound care, so next time you suspect a spider bite that needs treatment, (although we don’t wish that upon you) seek out your local Podiatrist!

Brachymetatarsia is a relatively uncommon disorder of the foot, but one that is interesting in its discussion. “Brachy” means short and “metatarsia” refers to the metatarsal bones (the long bones in the middle of the foot). A short metatarsal is one that is 5mm or more shorter than the length that it “should” be when compared to the adjacent metatarsals.

Patients develop this disorder due to premature closure of the growth plate in the affected metatarsal while the surrounding metatarsals continue to grow at a normal rate. The premature growth arrest can be congenital (something that we’re born with) or acquired throughout childhood. Congenital disorders that tend to lend themselves to brachymetatarsia include Down’s Syndrome, Turner’s Syndrome or bone enlargement. The most commonly acquired causes of ‘brachymet’ include trauma to the growth plate or infection both of which also arrest growth in the bone.

Most commonly, the 4th metatarsal is affected, and patients usually know something isn’t right, not by the symptoms they experience, but simply by the appearance of their foot. Their primary complaint upon presentation to a Podiatrist is that their toe “looks funny!” They may relay symptoms of calluses with associated pain beneath the adjacent metatarsals, a dorsal corn on the affected toe that rubs with shoe-wear, or contractures of both the affected digit and the surrounding digits. However, the conversation always leads back to the look of the toe. That is, their primary concern is cosmesis!

After x-ray evaluation, your Podiatrist will determine how short the metatarsal is in relation to the adjacent metatarsals, and although the number in millimeters doesn’t mean much to you as the patient, it means a lot in terms of how your Podiatrist can correct for this abnormality, should you opt for surgical correction.

Conservative options for Brachymetatarsia only treat the associated symptoms and will not treat the look of the digit. Options for treating the associated symptoms include padding, orthotics and trimming of corns and calluses associated with the deformity. However, since the primary patient complaint is the appearance of the digit, it is common that the patient selects surgical intervention.

In terms of surgical intervention, there are two choices: one-stage lengthening of the metatarsal vs. gradual lengthening of the metatarsal. One-stage lengthening involves a surgical break of the bone with insertion of bone bank bone into the defect. This will achieve lengthening of the metatarsal in one stage, but does have complications that involve compromise of the nerves and blood vessels surrounding the digit. Gradual lengthening of the metatarsal also involves a surgical break of the metatarsal bone, but rather than filling the defect, a distraction device is applied to the foot. Over a period of several weeks the distraction device is turned so as to lengthen the area of defect, allowing the body to make its own bone. The healing process in gradual lengthening does take longer but limits the risk to the surrounding nerves and vessels.

Your Podiatrist will recommend the surgical procedure that will work best for your case, with regards to the amount of lengthening required and your postoperative weight-bearing limitations. Keep in mind, however, that with any surgical procedure, although you will lengthen the toe and improve the overall alignment of the foot, you will have a scar on the top of the foot. Careful consideration, before opting for surgical correction for your Brachymetatarsia, is necessary and it is a decision that should not be taken lightly.

Even though the temperatures can often be stifling, someone has to get out and clean up your yard and garden this summer, so it might be that you find yourself spending this Saturday afternoon outside fulfilling those “yardly duties” of yours! One of the most commonly seen problems in patients who spend weekends tending their property is Contact Dermatitis. “Derma” meaning skin and “itis” meaning inflammation takes the guess work out of deciphering the meaning of Dermatitis. Thus, Contact Dermatitis is inflammation of the skin caused by the skin coming in contact with some object. Usually the skin reaction takes the form of a rash, sometimes in exactly the shape of the offending agent and other times spreading up the legs or arms leaving the patient questioning what it was that reacted with their skin. It can be itchy, painful or even burn and sometimes patients have symptoms of all three! It makes for a very uncomfortable few weeks as the rash clears, thus prevention in key.

Most people know what poison ivy is and that it causes a significant itchy rash in some patients when encountered. Other patients, not so much! Poison ivy is a form of Contact Dermatitis knows as “Allergic Contact Dermatitis.” When it comes in contact with the skin, in some patients it initiates a response by the body much the same as would occur in an allergic reaction to something that you’ve eaten. The only difference in this case, is that the trigger for the response was external (poison ivy plant) rather than internal (peanuts for example). The bodies immune system over-reacts to the poison ivy that has contacted the skin and cells are released that form the itchy rash we often associate with this plant. Other materials that commonly cause an Allergic Contact Dermatitis include nickel (found in jewelry), latex, hair dyes and shampoos or skin lotions containing fragrances.

In contrast to Allergic Contact Dermatitis, Irritant Contact Dermatitis does not initiate a response from the immune system. This reaction is simply a skin reaction that progresses the longer the skin is in contact with the offending agent. The most common cause includes household detergents and the reaction usually takes on the feeling of burning on the skin, rather than an itchy rash.

Deciphering between allergic and irritant forms of dermatitis can be difficult, but the good news is that both forms are usually treated in much the same way. Be sure that if you know you’ve come in contact with a material that reacts with your skin, you wash the areas immediately with cool water and soap, being careful not to increase the size of the area contacted. Cold compresses can help in situations where blistering has developed and the use of calamine lotion or over the counter anti-histamines (benadryl) can help relieve itching. Over the counter hydrocortisone creams can also help calm the skin reaction and alleviate symptoms quicker than without such creams, although the rash will resolve on its own over several weeks. If over the counter agents don’t seem to be doing the trick, seek out your physician, who can prescribe topicals that are slightly stronger, but accomplish the same tasks. Rashes on the legs and feet are well within the scope of your Podiatrist, so head to their office if symptoms persist!

Prevention is simple: don’t garden or tend to the yard! Although that might sound nice, unfortunately, avoiding the yard may not be an option, but there are some other steps you can take to protect yourself and your skin. Wearing pants, or long-sleeved shirts with gloves on your hands is the best option for protecting your extremities, in addition to wearing closed-toed sneakers or gardening shoes, however, all that clothing can be constricting and hot! Therefore, if you’re able to get up a little early this weekend, get out to the yard first thing before the temperatures have climbed up into the 90’s. You’ll be finished your work long before the temperatures rise, leaving the rest of the afternoon for lounging by the pool. In addition, if you’re one of the lucky ones and you know which plants or weeds in your yard induce a reaction in you avoid them and wait for another family member to come along and help you!

Some people sweat, and other’s sweat a lot! What makes the difference between these two patient populations is a condition known as hyperhidrosis. Hyperhidrosis literally means “a lot of water.” It is a condition that refers to an increased amount of perspiration (sweating) in a number of locations on a patient’s body including their face, hands, armpits and feet.

The greatest complaint for people with hyperhidrosis of the soles of their feet is the odor left behind. With sweating, moisture accumulates in socks and on shoes of such individuals and eventually odor-causing bacteria build-up resulting in an increase in odor, with subsequent embarrassment.

Although hyperhidrosis may be attributed to neurologic complications or sympathetic overactivity, a large percentage of patients with this condition have no contributing factors and suffer from this “just because.” In patients that have no predisposing conditions prevention is not the goal of treatment, but rather control of their excessive perspiration.

Hyperhidrosis can be very difficult to treat, and patience is a virtue while working with your Podiatrist to find a solution that works best for you! For starters, its best to keep feet clean and to change socks daily to prevent bacteria from colonizing on your feet, your socks or your shoes. Do not spray perfumes or body sprays on the feet in attempt to decrease odor as this can often increase the odor due to chemical reactions between sweat and perfume.

Antiperspirants are the first line in treating hyperhidrosis, as many patients immediately notice a difference and thus, success is achieved! Antiperspirants for the feet come in the form of deodorant sticks that one would use for the underarm; in fact there are some over the counter antiperspirant sticks that are indicated for use on the soles of the feet. Look for products that contain aluminum chloride hexahydrate, as they are most effective in treatment. Your Podiatrist may write you a prescription for such antiperspirants containing as much as 30% hexahydrate for prevention of sweating. Through prevention of sweating, antiperspirants are often successful in decreasing bacterial build-up and eliminating odor of the feet. These products are best applied to the feet twice daily: once in the morning and once in the evening, and are applied to the soles of the feet just as deodorant would be applied to the underarms.

For patients who suffer from hyperhidrosis due to sympathetic overactivity or neurologic complications, prescription medications that act on the peripheral nervous system can be tried. However, it is uncommon that your Podiatrist will recommend or even prescribe such mediations due to the potential side effects these can induce on the body.

Iontophoresis is a completely non-invasive method for attempting to treat hyperhidrosis of the hands and feet that utilizes water to pass a mild electronic current through the patients skin. Although not completely understood, the belief behind this theory is based on a cooperative effect of the electrical current and the water to increase the thickness of the outside layer of the hands and feet. Thus, the ducts for which sweat is released from the body onto the palms and soles become essentially “blocked.” Several treatments, on consecutive days helps patients reach a significant decrease in their perspiration, with subsequent maintenance treatments as needed, usually once every 2-4 weeks.

Finally, a treatment method that has gained popularity over the last 5 years or so is Botox injections. Botulinum Toxin, or Botox (the same material used on the face for decreasing wrinkles) can be injected into the soles of the feet for relief of hyperhidrosis. The toxin works by blocking a hormone in the body that is normally responsible for turning sweat glands “on.” This toxin, by blocking that hormone, turns sweat glands “off” and leads to a reduction in sweating in the areas where it was injected. Your Podiatrist will determine how many injections you will need and based on your clinical presentation, how often follow-up injection should be given. These injections are certainly not a cure for hyperhidrosis, but they control symptoms for a significant length of time; in some patients up to 7 months.

Hyperhidrosis is a difficult condition to treat, but your Podiatrist can guide you through your treatment options and find a combination that works best for you. Having feet that smell like roses is just within your reach!

Following in the path of last’s weeks Blog, where we discussed foreign object injuries to the foot, this week I would like to talk about broken toes! As with stepping on a foreign object, broken toes are more often than not suffered when there is a lack of shoe involvement: meaning when patients are barefoot. Of course, a broken toe injury can come at anytime, even with shoes, but that doesn’t seem to be the common occurrence.

Depending on which toe, the severity of the break, and exactly where the toe has been broken, can alter the course of treatment, so its important that we first talk about which bones are where in the anatomy of your foot.

A normal foot has 4 toes (2, 3, 4 & 5) and 1 hallux (“big toe”). Toes 2-5 have 3 small bones and one larger, longer bone. The small bones are called “phalanges,” and are named according to their location: distal (furthest from the body), middle and proximal (closest to the body). The larger bone is called a metatarsal and is named by the number toe that it corresponds to. To simplify, the third toe of the foot consists of the distal, middle and proximal phalanges and the third metatarsal bone. The hallux, or “big toe” contains only 2 small bones: the proximal and distal phalanx; and a larger 1st metatarsal bone.

Each bone communicates with the next across a joint, which is surrounded by a capsule and allows for motion to occur between those two bones: bending and extending of the toes. The joint of most importance, when dealing with toes is what’s called the “metatarsal-phalangeal joint” (MPJ). This is the joint between the larger metatarsal bone and the proximal phalanx. As we will discuss in a minute, determination of conservative and surgical treatment for a broken toe depends partly on the joint involved.

The typical “toe fracture” occurs when the toe is “stubbed” or “jammed” into the floor or into an object such as a step, or when an object is dropped onto the toe. The patient usually admits that injury has taken place while they were wearing no shoes, or slippers, neither of which provides any protection to the toes! Whether the toe was stubbed or an object was dropped on to it, pain will be immediate and swelling of the toe or toes will follow suit! You may immediately, or shortly notice bruising of the toe and/or changes in the look of the nail, if it has been injured. Rarely, the bone that has been fractured will be sticking out through the skin; an open fracture. Certainly, if bone is sticking out of the skin, a trip to the Emergency Room is a necessity.

Following injury, it is important to keep a close watch on the area involved for new pains, increased pain, or a worsening in appearance. Loss of sensation, numbness, tingling or an unusually cold toe should all throw up red flags and encourage you to seek medical attention immediately. In the mean time rest, ice, elevation and over-the-counter anti-inflammatory medications can be used to decrease swelling and pain to the injured area.

Differentiating between a fractured toe and one that is badly bruised is often difficult, unless the toe appears grossly deformed. Being that this is the case, if medical treatment is sought, an x-ray of the involved foot is likely. The x-ray will provide the Podiatrist will a lot of information to help guide your treatment: location of the fracture (if there is one), if the bones are displaced or if they are in good alignment, if a joint is involved in the fracture, how many pieces the bone is in, and whether or not conservative or surgical treatment is necessary.

If the fracture is located in one of the phalanges, is in good alignment and does not involve a joint, conservative treatment with the use of “buddy taping” and a surgical shoe to protect the toe while it heals will be initiated. If the bone appears as though it is displaced, involves the joint and is in several pieces, surgical treatment becomes a greater possibility. Surgery attempts to realign the pieces of the bone and hold them in position while they heal themselves.

As was mentioned before, involvement of the MPJ presents a bit more serious of a problem than if one of the smaller joints in the toe was disrupted. The MPJ plays a significant role in walking and provides a lot of structural support to the foot. Therefore, involvement of the MPJ will require surgery with “pin” fixation and non-weight bearing post-operatively to allow for appropriate healing to take place.

The moral of the story this week, as it was last week, is: don’t walk around without shoes on! Leaving the foot unprotected, whether it is the toes or the sole of the foot, greatly increases your risk of injury. Next time you get up off the beach blanket and head back to your summer beach house for lunch, make sure to put your shoes on and protect your feet.

The top four reasons not to walk around without shoes are as follows: sewing needles, glass, wood (toothpicks) and metal.

Year after year, once the Memorial Holiday has been celebrated, shoes are often left behind in the house, around the pool, or on the beach blanket! During the summer months, patients complain that shoes can be “constricting,” “hot,” and “uncomfortable,” but I can assure you that nothing will be more uncomfortable than a foreign object that’s found its way into the sole of your foot.

If you step on an object, the initial response is to immediately extract it from your foot, but this may not always be the best course of action. Unlike splinters on the hand, when you step on an object the potential for it to penetrate far into the sole of the foot is great, for the simple fact that you’ve stepped on it! Refrain from extracting the object yourself, especially if there is immediate and profound bleeding or if you have an immediate loss of sensation to the foot/toes or burning and tingling sensations. These may be signs that important structures within the foot have been penetrated and without visualization of those structures, more damage can be induced upon retrieval of the object! Getting yourself to the Emergency Room is your best course of action with this type of injury.

In such a situation it is important that you know a few things about your health to help guide appropriate treatment once you’ve reached the hospital. It is important to know if you have been immunized against Tetanus bacteria and how current your immunization is. If your immunization or “booster” shot was within the last 5 years, it is unlikely that you will need to receive a “booster” in the emergency department, however, if your last “booster” shot was greater than five years ago, you will need to a “booster” shot to ensure coverage against Tetanus bacterium. If you have never been immunized, you will be given a series of two injections: one for immediate immunization against tetanus bacteria and a subsequent injection for long-term immunization.

Knowing which medications you are allergic to and what your body’s response to taking those medications is will help the ER Physician in prescribing an antibiotic. Whether the foreign object stays lodged in the sole of the foot or not, it carries the potential to generate infection and initiate an immune response by the body. The reason it carries this potential is because most objects encountered while walking barefoot are not sterile and thus bacteria is inherent to them. Once the skin barrier is broken and the object enters the sole of the foot, infection becomes a possibility and the body identifies that object as foreign and works to “fight against” it.

After initial treatment has been started, the Podiatric Physician “On-Call” will come and evaluate your injuries in the emergency department. Depending on the type of object that is lodged in the foot and whether there is immediate danger to your foot or not, will determine the Podiatrist’s next course of action. They may first ask for x-rays, an MRI, CT scan or Ultrasound of the foot in order to locate the object, determine what, if any structures the object is penetrating and to better determine the next course of action in treating your injury. If there is imminent danger to your foot, meaning there are concerns about viability of the tissue, nerve penetration and compromised blood supply, the Podiatrist may want to take you to the operating room immediately to extract the object, clean out the tissues, and repair any damage.

No matter what the immediate course of action, once the object has been removed you will be given a 10-day course of antibiotics for prevention of infection. You will also need to follow up with the Podiatric Physician who treated you in the hospital, for evaluation of the site of penetration and to monitor healing.

The next time you think about walking around the house or the backyard without shoes, think again! Going barefoot is certainly not worth the risk of stepping on an object, lodging it into your foot and increasing your chance of infection with a subsequent recovery period during the beautiful summer vacation months!

For the diabetic population, especially those patients with neuropathy, walking without shoes is never a good idea. You are less likely to feel an object penetrate your foot, thus you are less likely to seek treatment and more likely to contract infection with poor healing outcomes due to the nature of diabetes.