Heel Pain

Heel pain is one of the most common complaints seen by podiatrists.  Patient experiencing heel pain can be suffering from multiple conditions such as plantar fasciitis, heel spur syndrome, bone contusions, stress fractures, Haglund’s deformity, Baxter’s neuritis, peroneal tenosynovitis, tarsal tunnel syndrome and posterior tibial tenosynovitis to name a few

COMMON SIGNS AND SYMPTOMS

The majority of patients will complain of sharp, severe pain most noticeable after periods of rest such as when they first wake up in the morning (post static dyskinesia).  Pain can be progressive first starting at the bottom of the heel before moving up and around the ankle.  Pain is usually alleviated with walking and moving around for a few minutes but can often become constantly achy and sore with too much activity.  

CAUSES

The most common cause of heel pain is overuse or neglect.  Overuse can occur with activities that involve prolonged standing, weight-bearing and ambulating especially with hard surfaces such as concrete and hardwood floors or inappropriate or non-supportive shoe gear. 

Often mild acute pain and inflammation is often our body's way of telling us something is wrong.  Failure to listen can often result in chronic pain and inflammation

AT HOME THERAPY AND PREVENTION

• Good shoes 

• RICE: Rest, Ice, Compression and Elevation

• Stretching

• Massage

• Orthotics/Insoles

• Anti-inflammatories

WHEN TO SEE THE DOCTOR

• If pain remains present despite a reduction in activity and/or a failure of normal home therapy.  

• In the presence of trauma (Normal heel pain is a response to overuse, however in the presence of acute trauma such as falls, blunt impacts, etc. Radiographs may be necessary to rule out fracture)

• If pain has persisted for more than a few days 

• If pain is moderate to severe

Flip Flop Season and Fungus! (Part 2)

In medical school a patient came to clinic, after a 20 year hiatus.  When asked about the reason for her visit she stated that she wanted to see if there was anything new with a 100% cure rate for fungal nails.  When told nothing was a 100% she laughed and said she’d see me in another 20 years…

The Cure! ....Patience

The goal of treatment is two-fold: curing the fungal infection and obtaining a normal nail.  Fungal nails have a slow onset therefore their treatment is slow.   Cure and noticeable improvements take 9-12 months.  Treatments prevent infection of the growing nail, not the infected portion. AKA you have to wait for a new nail to grow in and hope it doesn’t get infected along the way.

The gold standard: Tried and True

Oral medications boast an overall cure of 65% to 86%. This depends on multiple factors most prominently:

1. Thickness
2. Number of infected nails

Every treatment has pitfalls.  Not all fungi are created equal.

The contradiction for oral medications is liver toxicity.  Complications are rare and most accounts are from first generation drugs. Fungi are not created equal; some are round and some have tentacles!

It is important to limit use to correct drugs.  Nail culture and PCR limit over prescription of drugs and are best practice.

Topical treatments

Topical anti-fungal nail lacquers are best for toenails as penetration is prolonged.  Traditional medications have low success rates between 5-20%. Combining treatment with sterile nail debridement and softeners increases the penetration time with reported success in up to 77% of patients. 

Pedicure Tips!

• Ensure your nail salon uses instruments sterilized in a autoclave
• Bring your own instruments!
• Avoid foot soaks
• Cut nails straight across
• Avoid aggressive treatment of cuticles

For your safety and that of other patrons avoid non-medical treatment of nails if you have diabetes, neuropathy, poor circulation and active fungal or bacterial infection

Myth versus Reality – difficult pathologies have the most home remedies!

These home remedies have increased cure rates in combination with traditional therapies

• Vicks Vapor Rub
• Tea tree oil
• Snake root extract

New Kids on the block - court still in session, results are promising

• Laser therapy
• Keryflex

Nail Surgery

Minimally invasive complete and partial nail removal is an option for those suffering from painful nail overgrowth and pressure. It is a short in-office procedure with minimal risk. 

Flip Flop Season and Fungus! (Part 1)

With flip flop season in full bloom a common condition seen by podiatrist, fungal toe-nails (onychomycosis), becomes a common topic of conversation.  While this condition is not life threatening it is often painful and cosmetically displeasing.

It is characterized by thick, discolored and often ingrown toe nails that cause pain with pressure from shoes and walking.

Worry not, you are not alone!

Onychomycosis affects 10% of the general population, 20% in people over the age of 60 and 50% over the age of 70.  Fungus is an “opportunist” and exists everywhere.  It is more common on the toenails then fingernails.  It takes advantage of the poor circulation in the feet and loves the dark moist environment generated by shoes. 

Risk factors:  Diabetes, PVD, HIV, psoriasis, smoking, con-current skin infection   

Why see a Podiatrist?

Are you sure its fungus? Fungus is difficult to treat however, only 50% of nail problems result from fungus.  Other causes include chronic ingrown toe nails, warts, dermatitis, lichen planus, psoriasis, trauma, melanoma

As such definitive diagnosis cannot solely be based on appearance but requires both culture and biopsy.  This is 96% sensitive and aids in determining the best treatment option.

Home Remedies + Prevention

Prevention involves basic foot hygiene.  This includes regular sterile nail debridement, sterilizing shoes and insoles, changing socks daily, resolving underlying skin infections and avoiding occlusive shoe gear. 

Join us next week as we go over common treatments involved in the management of fungal toe nails!

The Podiatrist

What is a podiatrist?

The medical sub-specialty of podiatry has lived in obscurity since its inception in the early 20th century.  Today on rare occasions it may still be confused with “like” sounding specialties.  However the mystery behind podiatry lies in what a podiatrist does. 

Originally termed “chiropody”, podiatry has transformed its focus from a pre-dominantly geriatric population dealing with corns, calluses and fungal toenails to encompass a wide variety of pathologies. 

The popularity of running in the mid-1900s resulted in new complications affecting knees, hips and backs. These over-use injuries resulted in higher rates of injections, increased reliance on oral anti-inflammatories and surgery. 

Through the desire to avoid these more aggressive complications, podiatry found a niche and became ingrained in the world of sports medicine.  Addressing biomechanical imbalances and abnormal gait resulted in the development of orthotics. Orthotics, both custom and over the counter, decreased foot, knee and hip pain by decreasing the amount of stress and pressure brought on by prolonged physical activity.   

Building on these developments, podiatry continued to carve its own niche and expand its scope of practice eventually becoming a surgical specialty that addressed foot deformities that did not respond to conservative treatments; deformities such as bunions, hammertoes, flat feet, heel spurs and many more. 

Advances in medicine during the turn of the century saw the emergence of the epidemic, Diabetes Mellitus. This epidemic has plagued westernized countries and resulted in complications involving the eyes, kidneys and the feet. Today diabetic foot infections are one of the leading causes of hospitalizations and the leading cause of loss of limb.  As a specialty, podiatrists have unanimously risen to the occasion to become wound care and limb salvage specialists, decreasing the number of complete limb loss. 

The current generation of podiatrists is subject to intensive surgical and medical training requiring a minimum of 4 years of graduate medical education and 3-4 years of post-graduate residency training. While not universal the scope of podiatry encompasses all structures below the knee both medically and surgically. 

Podiatry as a medical specialty has evolved to encompass preventative care, sports medicine, foot surgery, wound care, limb salvage and reconstructive ankle surgery in the short span of a century.  It is no wonder that “what a podiatrist does?” is still somewhat a mystery as training has drastically changed in such a short amount of time.