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Description: The OPMA has taken the past 10 years of articles, media clips, foot health facts and general public information and bundled them in year groupings for ease of reference. There are 3 additional parts to this series.
Foot Health Advice 1996-1998 Foot Health Advice 1996-1998 Contents Gout and Pseudogout .......................................................................................................... 2 Hypertrophic Scars and Keloids ......................................................................................... 4 Limb Length Discrepancy .................................................................................................... 5 The War on Warts ................................................................................................................. 7 Corrective Toe Nail Surgery ................................................................................................ 9 Prescription Orthotics Explained .......................................................................................11 Foot Orthotics Advisory......................................................................................................13 Laser Surgery A New Approach ........................................................................................14 When to Refer for Orthotics ................................................................................................15 Timely Tips For Tennis Types ............................................................................................17 How to Easily Treat Acute Ingrown Nails...........................................................................20 Impressions .........................................................................................................................22 1 Foot Health Advice 1996-1998 Gout and Pseudogout Astute clinical judgement is crucial to diagnosing gout. Ninety percent of cases of gout occur in middle aged and elderly men postmenopausal women make up the remaining 10%. Gout can occur as a result of diuretic use or in association with chronic renal disease. It can also be precipitated by systemic infection ketosis or surgery. Gout is the most common of the crystal deposition diseases in which crystals of monosodium urate are deposited in and around joints. Clinical Presentation Gout presents as an acute attack of arthritis most often affecting the first metatarsophalangeal joint (podagra). The onset of the attack is very rapid usually occurring during the night and peaking within 24 hours. The patient will present with a very painful warm joint erythema and edema and may complain that even the bedsheet touching the area causes intolerable pain. The symptoms of gout usually resemble cellulitis and can be misdiagnosed as infection. Diagnosis The ultimate diagnosis of gout is made by identifying monosodium urate crystals in the synovial fluid of the affected joint or from tophi. Blood uric acid levels may are normal in the acute phases and therefore are not the most reliable criteria. Attacks of gout can be very acute lasting just a few days or more severe and prolonged lasting for weeks. Certain foods such as seafood organ meats and brussel sprouts can precipitate a gouty attack and alcohol consumption is notorious for causing exacerbations. The Importance of Treatment If acute gout is not treated it will progress to chronic gouty arthritis in which attacks become more frequent last longer and involve an increasing number of joints with a tendency towards incomplete resolution and polyarticular involvement. Untreated gout can also lead kidney stones and urate nephropathy. An alert practitioner will be able to manage acute attacks of gout and thus prevent chronic gout. The sooner gout is identified the sooner a treatment regimen can be implemented Treatment usually consists of anti-inflammatory medication rest avoiding offending foods and alcohol and preventing friction on the affected joint. Symptoms will usually resolve in two to three days. Long-term therapy to decrease the risk of further gouty attacks should include daily administration of allopurinol which inhibits xanthine oxidase. Uricosurics such as probenecid and sulfinpyrazone can be useful in dissolving tophi and urate crystals. Patients on uricosurics must limit their intake of ASA since it has a tendency to block the urinary action of these medications. Pseudogout Unlike gout pseudogout is not brought on by alcohol diuretics or kidney failure though it may occur following a surgical procedure. The most common site is not the big toe as in gout but more often the knee ankle elbow or wrist. In pseudogout deposits are of calcium pyrophosphate dihydrate crystals. Pseudogout affects men and women equally and usually occurs after the age of Pseudo-out appears as a hot painful swollen joint but is generally not as painful or as red as in gout. Radiographic examination will reveal calcification of the articular fibro and hyaline cartilage. In gout radiography would show a punched-out lesion or a mottled moth-eaten appearance. Treating Pseudogout Treatment of pseudogout involves the use of indomethacin and other non-steroidal anti-inflammatory drugs (NSAIDs or an intra-articular injection of a short-acting corticosteroid such as dexamethasone phosphate. The patient must also be counselled to rest apply ice and reduce stress to the area. Chronic pseudogout can lead to joint osteophytes subchondral cysts osteoarthritis joint narrowing and a consequent decrease in joint mobility At present there is no treatment available to remove pseudogout crystal deposits or retard the progression of joint degeneration. 2 Foot Health Advice 1996-1998 Summary A diagnosis of gout must rely on clinical skills a proper history and assessment of the symptomatology. Where it can be obtained an evaluation of synovial fluid aspirate will provide a definitive diagnosis. With proper diagnosis gout should not be confused with local infection and inappropriate use of antibiotics will be prevented. A patient diagnosed with gout should be placed on appropriate therapy to minimize the occurrence of chronic attacks that may lead to joint destruction. Proper therapy includes treatment in the acute stage as well as long-term control. Finally remember that abnormal uric acid levels do not always provide proper gout diagnosis. Hartley Miltchin DPM Canadian Footcare Practice April 1996 Vol. 1 No. 3 April 1996 by Hartley Miltchin D.P.M. 3 Foot Health Advice 1996-1998 Hypertrophic Scars and Keloids Keloid and hypertrophic scars are benign overgrowths characterized by excess deposits of collagen - both tend to be red pruritic and raised. But there the similarities end. Hypertrophic scars often improve with wound healing keloids do not. Keloids spread hypertrophic scars confine themselves to the initial site. Another striking difference is that keloids are more prevalent in dark-skinned people in a ratio of about 10 to one. Casual Factors The etiology of keloids is unknown although researchers believe that areas of increased skin tension may be involved. Hypertrophic scars by contrast cross joints or skin creases at right angles scar contractures tend to occur only on flexor surfaces. Another theory holds that keloids result from an auto immune response to sebum trapped in the dermis- they rarely appear in areas without sebaceous glands such as the palm of the hand and soles of the feet. Other possible factors include puberty and pregnancy both show pituitary hyperactivity and increased skin..pigmentatio and are associated with a higher incidence of abnormal scarring. Non-Surgical Treatment One approach to therapy is to allow keloids and overgrown scars to go untreated for six to twelve months since they can subside or even disappear. Keloids are especially difficult to treat - they can resistant - but fortunately are not very common. Various treatments are available (outlined below) but none seem to provide consistent results. Both types of scars may respond to topical bandages and cortisone. Compression bandages must be continuously maintained for several months and even so no complications have been reported. Zincimpregnated bandages are an alternative as with compression wrappings these must also be used for 24-hours a day for many months. Silicone gel pads placed over the lesion have had a relatively high success rate. Drug therapy is limited to cortisone injection - a highly popular option - which is given in phases. Care should be taken to keep the injection within the affected area and to avoid the surrounding healthy tissue. Surgery These lesions often cause unexpected surgical complications. Generally keloids can be surgically excised but the success rate is much higher with hypertrophic scars. Removal is done with primary closure using nonabsorbable sutures. Delicate tissue handling and hemostasis is helpful as are applying post-operative topical steroids. Keloid excision has a high failure rate with reported recurrences of approximately 55%. The traditional approach to treatment was excision followed by full-thickness skin grafting and or ionizing radiation. More recently laser excision (now possible through good hemostasis control) has been attempted. The lesion is allowed to heal before the procedure is repeated. If a practitioner is faced with performing surgery on a patient who is susceptible to hypertrophic scars or keloids some precautions should be considered. Most important the patient must be advised of the risk of additional lesion formation. It is crucial as well to develop a preoperative plan that takes into account the location of the incision and choice of suture make sure the cut follows an area of low skin tension possibly using a lazy S- or Z-type incision keep tension off the wound edges limit tissue trauma and maintain hemostasis minimize dissection of tissue use nonabsorbable sutures and operate with a simple or running subcuticular technique. Summary To date far more favourable results can be achieved when treating hypertrophic scars than keloids. The most common treatment for both these lesions remains cortisone injection (e.g. betamethasone sodium phosphate triamcinolone acetonide suspension). However new experimental dermatologic preparations are being developed. It is conceivable that effective therapy is on the horizon the hope is that practitioners will soon have access to better tools that will treat these lesions more successfully Hartley Miltchin DPM Canadian Footcare Practice April 1997 Vol. 2 No. 1 April 1997 by Hartley Miltchin D.P.M. 4 Foot Health Advice 1996-1998 Limb Length Discrepancy There are basically two categories of limb length discrepancies (LLD) functional and structural. Functional limb length results from altered lower extremity mechanics for instance one foot pronating three degrees or more than the other foot which results in a downward tilt of the pelvis to the short side. Joint contractures and axial malalignment can also contribute to functional LLD. Structural limb length discrepancy is a shortening of the skeletal system between the head of the femur and the ankle. Causes may include pathology such as Legg CalvePerthes disease or trauma among others. Functional arid structural LLD can sometimes be found in combination. In the general population the overall incidence of LLD is difficult to estimate many people are asymptomatic and it is not commonly measured. Of the asymptomatic patients many may be susceptible to future injury. Depending on which study you read significant LLD ranges from 3 mm to 22 mm and some authors believe treatment is only required when the patient is symptomatic. Compensatory Positions The most common compensatory mechanism for LLD is a functional scoliosis. Three compensatory positions of the body for LLD have been identified. Most Common pelvis tilts downward on short side shoulder tilts down on long side patient s head tilts down on long side level of fingertips uneven lower on long side pronated foot on long side Less Common lumbar scoliosis shoulders are level pelvis tilts downward on short side patient s head tilts down on long side level of fingertips uneven lower on long side Uncommon no spinal compensation head and shoulder tilt to the short side more often seen in children Measuring LLD Measuring LLD can be very inaccurate and difficult. The oldest and most common means is by use of a tape measure. The length between the anterior superior iliac spine and the medial malleolus is measured and compared between the two lower limbs. The drawback is that this method is relative and not very accurate. Some experts believe a CAT scan is a more appropriate means of measurement but it is expensive not readily available exposes patients to radiation and does not address compression or contracture in weight bearing. A solution is to palpate the iliac crests in weight bearing 5 Foot Health Advice 1996-1998 judging the level of the hand position determines the discrepancy and placing graduated blocks under the short leg aids in the calculation The same technique is used while the hands are on the anterior superior iliac spine and then on the posterior superior iliac spine. Making Adjustments Using an orthotic to correct pronation is an effective way to treat functional LLD structural LLD requires a lift. If patients have combined structural and functional LLD they may require both an orthotic and a lift. When there also is evidence of weakness in a particular leg muscle group strengthening exercises are recommended. Full-length foot lifts are recommended for LLDs 10 mm. Lifts should be introduced in stages to allow for mechanical adjustments. Heel lifts on the other hand may increase ground reaction forces - adding stress to joints in the lower extremities - and can contract the Achilles tendon making full lifts preferable. Limb length discrepancy may remain asymptomatic or can manifest itself in various ways as plantar fasciitis or hip knee or back pain. In all cases measurement of the lower extremities should be a standard part of the podiatric biomechanical exam. If LLD is. evident it should be treated accordingly whether it is structural functional combined symptomatic or asymptomatic. Hartley Miltchin DPM Canadian Footcare Practice October 1997 Vol. 2 No. 2 October 1997 by Hartley Miltchin D.P.M. 6 Foot Health Advice 1996-1998 The War on Warts We have literally centuries of documentation for the human wart and the lesion it produces on the hands and feet. And while we know now that the human papilloma virus is responsible our ability to treat it is limited. Unlike the antibiotic therapy that we can offer for bacterial conditions there are no oral or injectable medications which can kill these viral diseases. Still a wide range of treatment approaches are available and today s practitioner must help patients decide which of these many routes will work best for them. Most wart therapies can be divided into two categories topical solutions may enhance the body s immune response to that particular virus and more invasive physical measures. Lifestyle the need to be ambulatory and the extent of his or her activities tend to dictate a patient s treatment preferences. Topical solutions Many over-the-counter treatments may be effective when used properly. Chemicals or acids that can be applied to warts include salicylic acid lactic acid pyrogallic acid pedophylin cantharidin and glutaraldehyde. Each have some type of skin-altering capabiIity - keratolytic vesicular drying or cauterizing. In addition using chemicals over the long term can evoke the inflammatory response necessary to activate the body s immune system. To illustrate I once treated a middle-aged man who had been troubled with warts on his hands and feet for over 10 years. These lesions were variously treated over the years but he wound up in my office with a relatively large lesion (3 cm in diameter) on his heel which made it very painful to walk. I excised it with a radiosurgical device and cauterized the base of the lesion. There was a small recurrence at the center of the lesion and I decided that cantharidin would be optimal to prevent further spread. The patient had a significant local reaction to the medication and the lesion appeared to resolve. Obviously we can infer that chemical destruction of the tissue cuts the virus off from nutrients and or actually kills it. What is more interesting though is that the other lesions on his feet and hands began to heal (untreated) within a twoweek period. All of his warts were gone within two months I can find no other explanation than we had finally triggered the patient s immune response to the virus. An advantage of topical chemicals is that they can be used to control the amount of disability and pain that their application causes. To keep disability to a minimum and a patient at work - judicious use of a chemical may be the treatment of choice. There is a drawback the speed of cure is directly proporional to the degree of discomfort. Bleomycin and 5-fluorouracil chemicals used to treat cancer in the past have also been used successfully for warts. Physical therapy Physical modalities have been used in the past to eradicate warts including radiation and cryosurgery. Radiation was used during the 1940s but proved problematic tending to leave painful radiation burns and scars on the plantar of the feet which were significantly worse than the original lesion. Cryosurgery using liquid nitrogen has been quite successful in reducing warts quickly and simply. It seems to cause frostbite in the warty tissue by destroying enough of it so that it can no longer host the virus. Some patients need a local anesthetic to make. The application of liquid nitrogen more comfortable. Vapourization of the tissue with a C02 laser has taken the place of the hyfrecator. Charring or burning the tissue has been very successful but without curettage it is difficult to know whether the tissues have been burnt deeply enough to eradicate the wart completely. 7 Foot Health Advice 1996-1998 Curettage Complete removal of the tissue surrounding the virus has both advantages and disadvantages. The major advantage is that it shortens the treatment time considerably. In some cases - if the wart is very deep and long-standing - the discomfort over prolonged treatment with chemicals or acids (six to nine months) is far outweighed by the post-operative discomfort Straight curettage has been performed with a curette under local anaesthetic for many years. The problem with this procedure is that it is difficult to differentiate the verrucous tissue due to lesion bleeding and more force is necessary to cut through the tissue. Curettage after hyfrecation and laser give a good clean blood-free field. Radiosurgery I favor a more recent treatment for plantar verruca the radiosurgical unit. Following local anaesthetic the radiosurgical unit s thin wire loop electrode can be used to curette the wart away. This should be done slowly and in layers in order not to penetrate the superficial fascia otherwise it leads to scarring which can be more uncomfortable than the original wart. Manual blunt curettage of the remaining tissue helps to differentiate between the warty and healthy. tissues. The base then can be cauterized using the unit on the partially rectified hemostatic setting. Depending on the depth and. the diameter of the defect created the lesions tend to close within three to six weeks. Moderate post-operative discomfort can be controlled with over-the-counter analgesics. Usually a large dressing to disperse pressure is used for about four days after the operation and simple bandages afterwards. Small strips of 1 8-inch adhesive felt may be laid around the lesion to further prevent pressure while healing. Robert Goldberg DPM Canadian Footcare Practice October 1997 Vol. 2 No. 2 October 1997 by Robert Goldberg D.P.M. 8 Foot Health Advice 1996-1998 Corrective Toe Nail Surgery Toe nails require surgical treatment for a number of reasons. When conservative measures fail to give relief from discomfort infection or disfigurement a surgical correction may be the avenue of choice . Toe nails can become distorted either through trauma disease or congenital reasons. Diseases such as psoriasis and fungi (athletes foot) can lead to thickening and distortion of the nail plate. Trauma from dropping something on the toe nail may cause the matrix (root) to become distorted and make the nail thick and disfigured. Minimal trauma due to the toe nail hitting either a short or shallow shoe during skiing skating or running may also distort the toe nail. Some general diseases such as chronic obstructive lung disease can cause spoon nails . However incurvated and ingrown toe nails consist of the majority of nail problems which require surgical correction. An incurvated nail is one in which the matrix (root) is distorted at the nail plate so that the sides curl downwardly into the toe itself. If the nail plate is thin and brittle it may even cut through the tissue. A so called ingrown toe nail usually occurs from improper nail cutting which leaves a sharp hook along the side of the nail (Often done to attempt to get relief from an incurvated nail.) or due to splitting of the nail from trauma. If a sharp or rough piece of nail breaks the skin bacteria will enter and cause an infection. If this break in the skin is not dealt with in a reasonable period of time granulation tissue (proud flesh) develops. This tissue is red inflamed raw and enlarged. The enlargement of this tissue causes it to wrap around the sharp piece of nail to a greater degree and makes treating the ingrown nail more difficult. Modern surgical procedures date back to 1933. Ingrown toe nails which result strictly from improper nail cutting can frequently be dealt with by simply cutting away the sharp portion of the nail which is breaking the skin under local anaesthetic and filing the border of the nail adjacent to the tissue. A small cotton packing is placed between the tissues and the remaining nail plate to prevent further irritation of the skin. The packing is allowed to stay in place as long as the nail is shorter than the toe itself. Once the nail plate has grown beyond the nail lip the packing is usually no longer necessary. The ingrown toe nail which results from either a curved matrix (root) or an enlargement of the lip surrounding the edge of the nail can become chronic and necessitates either surgically narrowing of the nail plate or reducing the lip. Frost in 1950 described a procedure where the curved side of the nail plate was excised the skin opened and the portion of the nail bed and matrix was excised. Earlier Winograd had described a surgical procedure which simply cut away a wedge of tissue on the side of the nail including the nail plate bed and lip. Modern podiatrists now use procedures which do not require cutting of the skin or tissue around the nail. There are presently three common podiatric procedures for nail correction. One uses chemical cautery or burning of the bed and matrix (either by Phenol or Sodium Hydroxide). Another is radiosurgical ablation (cautery and vaporization of the bed and matrix) and lastly laser vaporization of the bed and matrix. Since there is no suturing and incisions are not made deeply into the toe generally much less discomfort is experienced by the patient. There is less likelihood of infection of the underlying bone since tissues close to the bone are not being invaded. Since there are no sutures involved the cosmetic result seems preferable. In all three of these procedures only the upper layers of the matrix and bed are being destroyed. The possibility of a spicule reoccurrence is small due to the cautery or burning effect of the exposed bed and matrix. Either of these three procedures can yield a good cosmetic and comfortable result in the hands of an experienced practitioner. When a toe nail becomes distorted due to trauma or disease and one wishes to remove it permanently due to cosmetic requirements or pain specific procedures for removal of an entire toe nail have also been developed. Earlier procedures (Symes) necessitated the surgical excision of the entire toe nail and matrix. In order to close this defect half of the end bone of the toe was excised and remaining toe was then folded over and sutured down to close the defect. In light of modern technology this now seems to be a great deal of surgery and discomfort which is no longer necessary. Unfortunately the Symes procedure yields a short disfigured toe which is cosmetically compromised. A surgical procedure to cut away the nail matrix and bed for the entire nail in a similar fashion to that of the Frost procedure for partial nail was developed by Zadik. As in partial nail resection tissues are cut and sutures are placed into the toe. This leaves scarring and significant more discomfort due to greater tissue damage than modern procedures. Again chemical radiosurgical and laser procedures can be utilized for destruction of an entire toe nail. There are still no sutures or no cutting of the tissues. Following local anaesthetic the nail plate is gently eased off the toe and the exposed nail bed and matrix are cauterized (burnt) to destroy those tissues which generate the nail plate. 9 Foot Health Advice 1996-1998 Post-operative care is simple dressings and soaks to care for the burn as it heals. A vast majority of patients require only Tylenol or Aspirin for any post-operative discomfort. Many persons cease taking analgesic medication the day after the procedure. Patients are immediately ambulatory. After having the foot elevated for twelve hours unrestricted walking is permitted in a large or cut out shoe. Ingrown and disfigured toe nails need not be a chronic and painful condition. Modern podiatric procedures can permanently correct these conditions with minimal discomfort and disability. Robert Goldbert DPM March 17 1997 by Robert Goldbert DPM 10 Foot Health Advice 1996-1998 Prescription Orthotics Explained Prescription Orthotics Thanks to your feet you are a natural runner born to run Your feet are a structural marvel designed to support and propel the body while simultaneously absorbing shock and adapting to all types of terrain. Somewhere between 3000-10 000 or more steps are taken each day and with each step one must raise their body weight an inch or so. Running or jumping increases the forces of body weight by 3 to 4 times. Even slight abnormalities in joint and muscle function and or anatomy may result in overuse injury. If properly prescribed orthotic devices can assist in the elimination some of these problems in runners. Your Foot Mechanics Runners must stretch wear good shoes and build mileage gradually but problems can still occur. Biomechanics is the science of function and movements of the body. Biomechanical orthotic devices function by influencing more normal function of the feet and legs. How is this accomplished Perhaps the easiest way to explain the sequence of events is by relating to potential problems in another area of the body namely vision. We all know that near sightedness is the inability to clearly see at a given distance. The light entering the eye is not being properly focused by the lens onto the retina. Glasses adjust the light beam to match the eye lens. In a similar manner orthotics alter the terrain to match one s specific foot alignment. When wearing corrective eye wear there is no squinting or straining to see distant objects and similarly with orthotics it is not necessary for the foot to twist or excessively change its angulations to reach the ground. Normal function is promoted. Here ends the analogy. Unlike the eyes the foot bone s connected to the ankle bone the ankle bone s connected to the shin bone.... and as a consequence of this chaining of body segments abnormal foot function can often be a cause of knee and back pain. If made precisely orthotics will prevent abnormal strains while allowing for normal motion. Beware of Imposters Today everyone is selling shoe inserts and calling them orthotics. Shoe stores sporting good shops shopping mall kiosks and other aggressive entrepreneurs are taking advantage of unsuspecting consumers. The most common methods for sizing the foot are ink pad prints impressionable foam material and on the more glamorous side electronic flat bed scanners and pressure mats linked to computer imaging. For every image there is a corresponding sales pitch. In most cases the end result is an in stock arch support and an empty wallet. Sometimes a true custom insert is made except unfortunately it contains the contours of faulty foot These expensive supports push up against the arch but don t control any phases of the gait cycle. Is there any wonder these imitations are causing medical precriptive orthotics to appear as expensive and unnecessary A True Prescription for the Runner Podiatrists determine the diagnosis by physical and Xray examination. Weight bearing (standing) Xrays allows Podiatrists to determine and measure the degrees of deformity present as well as to predict the possibility of its further progression. At times when physical and Xray examination are inconclusive a more in depth evaluation of abnormal foot function is achieved with the Electrodynogram (EDG) system the EKG for the feet Seven electrical sensors are placed in specific key locations on each foot. They measure and record the duration and intensity of forces that occur throughout the feet. The data is computer analyzed taking into account the time of occurrence strength of pressures or shock forces sequence of force application and all interrelationships between individual sensors. The information is then correlated with established normal values to produce suggested diagnostic and treatment considerations. With this revolutionary diagnostic tool it is now possible to obtain quantitative values of abnormal function and further demonstrate improvement of function (with orthotics). The EDG is also useful in documenting faulty shoes ineffective orthotics or minor limb length discrepancies. At a qualified laboratory skilled technicians create the orthotic from various materials depending on the degree of foot control required and the activities of the individual. In general the more rigid the device the more precise the control of foot mechanics. Bulk is an obvious problem. The device is of no value if the foot slips out of the shoe. There is little or no problem in fit for athletic wear with a proper orthotic. Fashion or dress wear often require a compromise of control so that one would be better served to have a secondary device for your non- 11 Foot Health Advice 1996-1998 athletic shoes or other endeavours. Runners need lots of cushioning low bulk and good stability. A couple of follow up visits to ensure perfection are required. Slight adjustments may occasionally be necessary. The Secret to Walking & Running True prescription biomechanical orthotic devices are made from plaster casts of the feet taken in a precise position to capture all the angular relationships between the various segments of the foot. This is a multi step process. During the casting process the foot cannot be supporting any weight of the body as this will create distortion to the contour of the foot especially the heel area. Of utmost importance the foot must be positioned into its anatomically defined neutral position. The Podiatrist first locates the ideal state for your foot the neutral Subtalar joint position. This is the joint immediately beneath the ankle and shock absorption at heel strike is one of its most important functions. The final step is alignment of the forefoot to rearfoot. This can only be accomplished by pushing upwards from the under surface of the foot on only the 4th and 5th metatarsal head. It should be evident that this final step cannot be performed with foam impressions or high tech computer imaging on scanners or pressure carpets. Go RUN Around the World You will walk over a 125 000 miles in a lifetime on your only pair of feet. There are no trade-ins available. These original factory parts must last a lifetime. Why then allow an aggressive or virtually untrained entrepeneur to mess with your feet legs knees or back While it is true that proper orthotics are expensive they do last for years and hopefully your feet are worth it. Barry Noble DPM March 17 1997 by Barry Noble DPM 12 Foot Health Advice 1996-1998 Foot Orthotics Advisory Are you being told that you need orthotics when you complain of foot pain Consider You may not need orthotics at all Ask Just how qualified medically is the person wanting to treat your feet Caution There are retailers and many others in the health field attempting foot care as a sideline. Why Many ant to sell you orthotics. Some say theirs are the best. Helpful Think about trying other treatment modalities that can give you the relief you seek. Podiatrists will often alleviate foot pain without orthotics if possible. Recommended Get a diagnosis by a Doctor of Podiatric Medicine (D. P. M.) and ask what (other than orthotics) can be done for your feet. See if you can get some on the spot relief. If orthotics are needed There are many types of orthotics and many ways to make them. Some succeed others fail. Reason Adhering to strict biomechanical principles when making orthotics is the key to treating imbalances such as flat feet bunions heel and arch pain & calluses. Your podiatrist understands this fully. In many cases others with less foot training take shortcuts hoping for the best. You should know which treatment will work best for you before getting orthotics. Robert Chelin D. P. M. April 15 1997 by Robert Chelin DPM 13 Foot Health Advice 1996-1998 Laser Surgery A New Approach What is a laser A laser is a device which generates an intense finely focused beam of light known as the laser beam. This laser beam permits surgery to be performed more safely and conveniently for patients. This laser turns the water in the cells to steam called vaporization. There is no burning. Is laser surgery a new technique Lasers have been used in surgery for 20 years by eye surgeons and other specialists. Laser surgery to treat foot problems was introduced in Canada by our office in 1983. What are the foot problems best treated by laser surgery The laser beam of light is used in place of the scalpel to remove warts ingrown nails fungus infected toenails and some deep-rooted callouses among other foot problems. What are the benefits of laser surgery for foot problems Laser surgery takes advantage of the properties of lasers to remove tissue without many of the undesirable side effects that sometimes result from using a scalpel. The laser light vaporizes the affected tissues almost instantaneously and so precisely that normal surrounding tissues are not affected. The unique property of the laser is that as it vaporizes and destroy diseased tissue it also sterilizes and stops bleeding in the surrounding areas. Result much less tissue injury and swelling after surgery which in turn results in reduced pain and discomfort. There is faster recovery with better healing for the patient and chances of infection are decreased. There is also a cosmetic advantage because there is usually no scar formation after laser surgery. With the laser it is frequently possible to complete treatment in one visit while with other techniques many visits or even hospitalization may be required. Where is laser surgery done Laser surgery is performed in our office. The patient is first given a local anesthetic and then the laser light is beamed on the affected area. The entire procedure is completed in a very short time and the patient is able to walk out of the office after the procedure. Post-operative discomfort is minimal. Is the laser like an x-ray No There is no ionizing radiation present in the laser beam so there is no danger of radiation exposure. In fact lasers are all around us today not only in medicine. For example supermarket checkout counters use lasers (of a different type) to read the universal product code on packages. Lasers are used for many things from more accurate surveying to welding to drilling holes in baby bottle nipples. What is in the future for lasers Lasers have an important role to play in the future of medical treatment which is why we are so pleased about having today s most advanced carbon dioxide laser manufactured by Johnson & Johnson. Because of the many advantages to the patient lasers are here to stay to assist us in the treatment of many medical disorders. Lloyd Nesbitt DPM Lloyd Nesbitt is the former president of the Canadian Podiatric Sports Medicine Academy and Ontario Podiatry Association. He is currently in private practice in The Madison Centre North York. Copied from www.lloydnesbitt.com with permssion of Lloyd Nesbitt DPM March 17 1997 by Lloyd Nesbitt DPM 14 Foot Health Advice 1996-1998 When to Refer for Orthotics Recently there has been when considerable over-utilizaation with orthotics. Therefore how is the physician to determine when an orthotic device is indicated what type of orthotic should be used how it should be made or who should be making it These are all questions that commonly arise. In some cases the answer may be that orthotics are not needed at all. Biomechanical Foot Problems Pronation is a common finding with patients. It can lead to plantar fascutis heel spurs bunions neuromas and other foot complaints. Shin splints and patello-femoral syndrome are usually related to a biomechanically unbalanced foot. Your Quick Biomechanical Analysis Pronation Calluses inferior to the second and third metatarsal heads are indicative of shearing forces during pronation. Calluses at the medial aspect of a hallux or heel result from pronation as well. Look at your patients standing as their high arches may flatten upon weight bearing. Rigid pes cavus Calluses inferior to the first and fifth metatarsal heads occur with a rigid high arch. When combined with overuse syndromes these structural imbalances warrant the use of orthotic devices along with other treatment modalities. If the patient is asymptomatic but has a significant structural abnormaility treatment with orthotics on a preventative basis is usually worthwhile. Assessing your patient s existing orthotics If your patients orthotic devices are not working for them have them stand on the orthotics to check whether or not the orthotics are repositioning their feet adequately in a neutaal subtalar joint position. Do they pronate over them If on the other hand their orthotics are bothering them there may be too much correction for the patient to tolerate in which case the orthotics should be adjusted. Methods of Fabrication of Orthotics Research in the podiatry profession in the past 25 years has demonstrated that a neutral position plaster of Paris non-weight-bearing casting technique is preferred for the fabrication of orthotics. Podiatrists hold the subtalar joint in its neutral position and push up against the fourth and fifth metatarsal heads to lock the midtarsal joint. This provides the orthotics laboratory with a corrected position cast of the foot. This is a key step in the fabrication of orthotic devices. Many people other than podiatrists tend to use a foam impression for the fabrication of orthotics. However if the foot is placed in a foam box then a deviated weight-bearing position of the foot is captured which is inaccurate. This leads to guesswork in trying to control the foot mechanics. Computerized orthotics There has been a lot of misleading promotion taking place lately regarding so called computerized orthotics. Patients step on a force platform and a high-tech digitalized read-out of their weight-bearing feet is shown on a screen providing a nice gait analysis. This is very impressive to the patient and leads them to believe they are getting computerized orthotics. The fact is however that the orthotics themselves are often ready-made standard-sized items that. come off the shelf. The devices usually do not have a heel cup that will stabilize the rearfoot. As a result patients wind up with devices that push up against the arch during static stance and do not control the dynamics of the walking cycle. The end results are therefore variable. The devices may seem comfortable to the patient but they are not corrective. Therefore treatment of choice is to have an orthotic device fabricated from a cast of the foot. Other Treatment Modalities 15 Foot Health Advice 1996-1998 Frequently in podiatry we find patients do not require orthotic devices. In many cases the old standby treatment modalities including rest ice compression and elevation work well. Taping may be helpful along with massage therapy and strengthening and stretching exercises. Accommodative padding such as moleskin or one-eighth inch adhesive pads work well to alleviate pressure points. Heel pads or over-the-counter arch supports may provide temporary relief. Overuse syndromes of the foot may respond to palliative treatment temporarily. However if the foot imbalance is significant then properly made orthotic devices work well in correcting and preventing these biomechanically related foot problems. LLOYD NESBITT DPM PATIENT CARE CANADA VOL 9. NO 5 MAY 1998 16 Foot Health Advice 1996-1998 Timely Tips For Tennis Types Tennis players of all skill levels can improve their health along with their game by using some simple measures for conditioning technique injury prevention and equipment. Conditioning and Skills To improve your heart and lung conditioning consider a running program. Running three to five times a week will help you sustain the stamina for a top level of play through long matches. Get expert instruction in both conditioning and technique. The pros will not only help you with technique but also provide you with a fitness program to suit your physical condition and level of play. Work on all-around flexibility and strength. Consider consulting a sports physiotherapist or medical professional who can recommend a program to suit your body type. Preventing Injury Warm up before starting to play without fail. And remember that a warm-up means getting warm. Start with brisk walking or easy jogging to get your muscles warm then stretch for several minutes. Consult a qualified instructor and develop your own warm-up routine centering on muscles that come into play during a tennis match. If you are prone to ankle sprains tape up with the proper athletic product or consult a sports shop or healthcare professional for an ankle brace designed for tennis. (For advice on other injuries common in tennis see Court Trials Coping With Common Tennis Injuries below.) Calf muscles can get tight in tennis. Do lots of runner s stretches before between and after matches (figure 1). These are especially good for women who spend time in high- heeled shoes. Drink lots of water before during and after your match. Avoid caffeine alcohol and drinks that are high in sugar. Ongoing sore feet or legs in tennis may be a result of a mechanical foot imbalance. This can often be corrected by taping an offthe-shelf orthotic insert or a custom-made orthotic device prescribed by a healthcare professional. Equipment Wear tennis shoes for stability and cushioning (see Selecting Tennis Shoes below). Don t wear running shoes which are designed for forward motion and don t protect as well against an ankle sprain. Socks have improved. Try those for tennis that wick away perspiration and reduce friction. Reduced friction can help you avoid blisters. Choose the right racket (1). Your arm should not get tired swinging it. Mid-level string tension will absorb shock but give good power. And as you grasp the handle a finger s width should separate the tip of your middle finger from the crease at the base of your thumb. Keep a couple of small adhesive bandages in your bag in case you need them for foot or hand blisters. Game Point Tennis is a great way to get muscles working enjoy time with a friend or three and test your ability. The tips provided above can help you ace the sport without double-faulting on your body. Reference Harding WG III Elbow pain in young tennis players selecting the right racket learning good technique. Phys Sportsmed 1991 19(9) 135-136 Selecting Tennis Shoes 17 Foot Health Advice 1996-1998 Wear shoes that are designed specifically for racket sports and support your feet well. Replace worn-out tennis shoes. Patches or other repairs are temporary at best and excessively worn shoes can affect both your feet and your playing style. Never play in improperly fitted or borrowed shoes. When buying shoes look for those that support the arch firmly and allow room to move your toes. At the store try tennis shoes on and practice some on-court moves to make sure they fit and feel comfortable. As a rule more expensive shoes are of better quality but not always. Look for Reinforcement at the toe to protect your foot and minimize wear when the toe drags on the court. A well-padded sole at the ball of the foot which is where most pressure is exerted. Sturdy sides of the shoe for stability during side-to-side motions. A well-cushioned heel for absorbing jarring forces. Ample room in the toe box to prevent blisters. A firm and well-padded heel counter (back and sides of heel) for support. Court Trials Coping With Common Tennis Injuries Even if they take precautions to avoid injury tennis players sometimes get hurt. Here are pointers on how to deal with some of the most common tennis problems. Corns and Calluses Corns and calluses indicate pressure friction and imbalance of the foot. If you have calluses place 1 8-inch or 1 4-inch moleskin or felt on each side of the callus to reduce pressure until you can get proper medical help. Do not use commercial acid corn cures because they can lead to skin irritation and infection. Because most corns and calluses are signs of some underlying mechanical problem they cannot be eliminated permanently until the problem itself is corrected. Seek professional attention. Simple corrective procedures can relieve disabling problems. Tennis Leg Sudden movements of the foot and leg may result in tennis leg or a muscle tear deep within the calf. Never play with calf muscle pain. Seek medical help. Tennis Elbow Bending the elbow during a backhand swing an improper racket and weak muscles can all contribute to pain in the elbow (1). If you have persistent elbow pain take a break from tennis for a few weeks. Icing can also help. If the pain continues see a physician who may prescribe an elbow strap strengthening exercises and other measures. Tennis Toe Tennis toe is characterized by severe throbbing pain beneath the toenail. Symptoms include vague swelling of the toe and purple discoloration under the nail. The discoloration is from bleeding which may appear as vertical streaks beneath the nail. The condition usually affects the big toe or the one next to it. Tennis toe is often caused by modern tennis shoes which give such good traction that the foot is forced to the front of the shoe during sudden stops thus traumatizing the nail. Shoes should have a finger s width of room in front of the toes. 18 Foot Health Advice 1996-1998 Initially you can use cold packs and painkillers like aspirin to provide relief if the pain is severe. Placing a 1 8-inch-thick felt pad on the skin behind the base of the nail can help you prevent or cope with the problem as can trimming the nail. Medical care can also help. When to stop when to resume Swelling stress and strain won t necessarily mean you have to stop playing altogether. You may just have to scale back. Assessment and treatment by a medical professional can pave the way to pain-free playing. Don t try to return to full tennis activity immediately after an injury or other forced layoff. Return gradually and slow down if you feel pain. Get professional advice if you re unsure of how to resume your program. Reference Case WS Acing tennis elbow. Phys Sportsmed 1993 21(7) 21-22 Remember This information is not intended as a substitute for medical treatment. Before starting an exercise program consult a physician. Dr Nesbitt is a podiatrist in private practice in Toronto. Copyright (C) 1998. The McGraw-Hill Companies. All Rights Reserved May 1998 by Lloyd Nesbitt D.P.M. 19 Foot Health Advice 1996-1998 How to Easily Treat Acute Ingrown Nails Patients often wait to present to their physician with an ingrown nail after it has become acutely infected. Generally most physicians when presented with these cases would prescribe antibiotics and perhaps suggest the patient soak the foot in lukewarm water and Epsom salts. While this calms down the infection it really doesn t correct the problem. A partial nail-border removal and matricectomy is the treatment of choice. Most podiatrists use this procedure to permanently correct ingrown nail problems and find that a total nail avulsion is rarely necessary. Providing On-the-Spot Relief When the patient first presents to your office and you want to schedule surgery for a later date you can provide immediate relief without the use of local anesthesia. Simply (and painlessly) excise the distal aspect of the offending nail border with a nail nipper The patient usually has instant comfort. The corrective procedure can then be scheduled for a later date. Surgical Procedure For the past 15 years I have been using a carbon dioxide laser to treat ingrown nails. Some podiatrists use a laser while others use the older method of alcohol phenol matricectomy. Both procedures work well although the laser seems to be more appealing to the patient. With the laser there is less post-operative pain and swelling. Furthermore there is less drainage and faster healing. Some physicians may prefer to simply send the patient to a podiatrist for treatment. However if there is no podiatrist in your area here s how to do the procedure Anesthetize the hallux then apply a tounniquet to its base. Then use an English anvil nail splitter Slide tile flat side under the nail so you can cut the offending nail border back to its base (along the medial or lateral margins). With a 62 blade on a Beaver handle extend the nail cut proximally under the cuticle to the base of the nail. You will feel the resistance against the blade give - you ll then know you are.through the base. Use a periosteal elevator (Freer elevator) to free-up the nail from the skin margin and subsequently from the nail bed. With a straight hemostat grasp the nail. It is important to grasp it as proximally as possible so the nail does not fragment off. You will see a feathered edge at the proximal portion and then you know you have the entire segment. To make sure there is no nail spicule remaining use a curette. Apply 89% phenol to a sterile cotton swab. (Remove some of the excess cotton from the cotton swab first.) Be careful to only use a slight amount of phenol so as not to create a chemical burn on the adjacent skin. Apply under the eponychium and against the matrix by rolling the cotton swab back and forth for about 30 seconds. 20 Foot Health Advice 1996-1998 Remove the applicator stick and flood the area with alcohol in order to dilute the phenol. Repeat steps 7 and 8 a second time. Release the tourniquet and let the area bleed then apply compression with sterile gauze until the bleeding stops. (Bleeding is usually only slight.) For the dressing spray on povidone-iodine (Betadine) apply Telfa 2 x 2 s Kling and Coban 1 or 2 elastic wrap for compression. Secure with 1 adhesive tape so the bandage doesn t slip off. Postop instructions to the patient Have them keep the area dry over night elevate the foot and take acetaminophen (e.g. Tylenol) prn for discomfort (which should be mininal). Instruct the patient to return to the office the following day at which point the bandage can be removed. Telfa allows the removal of the bandage to be painless. The wound forms an eschar within a week or two. A bandage strip can be used daily and removed at night to promote drying of the surgical site. This procedure for an ingrown toenail works well. In fact patients can walk comfortably right away and can usually return to any sports activity within a week. LLOYD NESBITT DPM PATIENT CARE CANADA VOL.9 NO.7I JULY 1998 July 1998 by Lloyd Nesbitt D.P.M. 21 Foot Health Advice 1996-1998 Impressions Believe it or not factors other than your professional competency will affect patient s confidence in you. First impressions can become lasting impressions and convey many messages to your current or prospective patients. Professionals must strive to provide quality service and a pleasant atmosphere to maintain high standards of care. Most footcare providers must charge a fee for service consequently patients expect full service in return. First impressions are so important because they are a direct reflection on you. There are certain aspects of any professional practice that should be focussed on to ensure patients first impressions become long lasting impressions. Some important key areas we should pay attention to are friendly knowledgeable polite staff and a clean presentable office clinic environment. The patient s first contact with your office is a telephone call. Ensure that the individual(s) who is answering the phone is knowledgeable about your services fees hours parking transit routes etc. This person should have a clear speaking voice be articulate friendly patient and above all PLEASANT. This staff member should convey a sense of compassion to the patient since most people calling have pain have fears about their first visit and a sense of urgency. Try to convey the impression that the practitioner is indeed gentle caring and very competent. Show the patient that you will attempt to accommodate them at the earliest available appointment time. Evening early morning and or weekend appointments are so important to accommodate today s working schedules. Minimize telephone on hold times. Make sure your answering machine is high quality. This ensures accuracy of messages and reduces annoying static and garbled outgoing messages. New patients should be greeted with a smile and some pleasantry prior to administrative matters. One might want to ask a patient Were you able to find our office ok New patient s should be referred to as Mr . Mrs. or Ms. unless they specify otherwise. Reception areas are key gateways to treatment areas and are the first physical contact the patient will have with you. This area should be neat clean and comfortable. Fold-up bridge chairs are inappropriate especially if a patient must wait to be attended to. Magazines should be current and cover a wide range of interests i.e. Golf Digest People Chatelaine Car and Driver Readers Digest Entrepreneur etc. Children s books should also be included. Piles of Newsweek and Time magazines dating back to the turn of the century are unacceptable as are professional journals. The magazines should be kept tidy on a regular basis and replaced when tattered or outdated. The room should be decorated in warm colours and fabrics to create ambiance and comfort. Stark white under fluorescent lighting is very intimidating. Avoid posters pertaining to medical treatments drug therapies etc. No one wants to stare at pictures of fungus toenails. Nicely framed artwork is pleasant to the eye as well a good conversation starter. If music is playing make certain that it is at a low volume and isn t hard rock or similar. Letters from patients are also a nice idea for people to read while waiting because they convey previous patient satisfaction and confidence. A matter of debate is whether the front desk area should be sectioned-off (glassed) from the reception area. I personally believe that a glass partition is of the utmost importance. Waiting patients should not be subjected to the receptionist s telephone calls patient interaction and or financial transactions. These should be regarded as private matters. Also in the front desk area fees should be posted and visible to patients. 22 Foot Health Advice 1996-1998 The next area of concern is the treatment areas. Patients should be escorted from the reception area to the treatment room. Many of the patients we see are seniors therefore I recommend a separate chair be placed in the treatment room for their use in removing their shoes socks hose. Podiatry Chirdpody treatment chairs are too high and awkward for patients to perform these tasks. Hartley Miltchin DPM Networking March 1998 Vol. 1 No. 1 March 1998 by Hartley Miltchin D.P.M. 23