A patient came in the other day with a swollen tip of her second toe. She also had a funny looking, thick toenail and really thought that was the cause of her pain and swelling. She related that she had been experiencing throbbing pain, redness and swelling for several months in just the tip of the toe. It had never spread or gotten much worse. She had never experienced drainage or infection symptoms around the toenail. She was unable to wear a closed in shoe and was to the point that she wanted her toe amputated. She had been treated with topical anti-fungals and antibiotics without much result. She was sent to me for another opinion after taking two months of oral anti-fungals and having no change in the nail or toe appearance. What a strange presentation….or is it?
Sausage toe is a whimsical term used to describe a red, hot swollen toe often seen in psoriatic arthritis. It can also be seen in Reiter’s syndrome and other seronegative arthropathies. In English, a non-rheumatoid type arthritis. Sausage toe is inflammation of the distal interphalangeal joints (tip of your toe and adjacent knuckle) that looks like a sausage or lollipop. In psoriatic arthritis, it is often accompanied by nail changes that mimic onychomycosis or a fungus in the nails. The nails can be pitted, yellow, thickened, fragmented, and lifting from the tip of the toe. Psoriatic arthritic can occur without the typical skin changes seen in psoriasis, but most patients have some skin lesions.
Sausage toes should be treated aggressively to decrease the inflammation and joint destruction. Long term inflammation can lead to erosive changes and permanent joint pain and stiffness. Joint ankylosis (complete fusion of the joint) can occur in severe cases. Basic treatment starts with nonsteroidal anti-inflammatory drugs, exercise, physical therapy and education. Patient should be taught the “move it or lose it” principal of arthritis management. Exercise and mobilization of the joints, but not overuse and abuse, should be reinforced. Some patients need more aggressive treatment, and this should be part of a comprehensive treatment plan by a rheumatologist.
Sausage toes should not be ignored. They can be caused by many factors such as trauma, infection, osteomyelitis (infection of the bone), and many different rheumatologic disorders as discussed. If you experience a painful, red, swollen toe that just seems to persist; seek the opinion of your podiatrist. Treated early, sausage toe can just be part of a whimsical story instead of a long term disability.
Tuesday, September 22, 2009
Tuesday, September 15, 2009
Why Do Some Younger People Get Arthritis in their Ankles?
Younger patients can experience arthritis in their ankles. There is no age limit, young or old, for this painful disorder. Some people have arthritis caused by a systemic disorder like juvenile rheumatoid arthritis. Most have a more traumatic type of arthritis caused by an injury.
In the majority of younger patients with ankle arthritis, their arthritis is usually a secondary effect from too many ankle sprains. Most can relate a twisting type of injury which caused a deep cartilage injury that is often called osteochondritis dissicans. This has been seen to occur with no obvious trauma, but most can relate a history of severe sprain. Over time, the injured cartilage starts to deteriorate, then flake and finally many patients have bone on bone contact which is extremely painful.
Osteochondritis often causes significant pain, swelling and stiffness in the ankle. Patients come in several months after experiencing a bad sprain complaining of continued popping, instability, stiffness and pain. Some complain of severe discomfort, but most relate a chronic annoying ache.
Ankle sprains should not be ignored, because many lead to chronic instability and eventual arthritis. A physical examination by your podiatrist is usually followed by x-rays. If plain film x-rays are negative, and you have had pain for more than 2 months from an ankle sprain; an MRI is indicated to rule out a cartilage injury of the talar dome. This MRI can evaluate the cartilage of the talar dome for obvious flaps and for subchondral injury to the underlying bone. A chip fracture can be quite painful and feel like a clicking every time you move your ankle.
Conservative therapy for osteochondritis includes bracing, physical therapy, anti-inflammatories and rest. Many people do well with just conservative therapy and maintain their joints by working on their proprioception and strength.
Unfortunately, surgical intervention of ankle arthriscopy is often needed to remove the cartilage fragments and place tiny drill holes in the deficit to encourage the formation of fibrocartilage or scar tissue. Severe defects may require cartilage grafting.
So, for all you young sports stars out there: Remember that ignoring multiple ankle sprains and ankle instability is usually a prescription for long term arthritis. Osteochondiritis leads to good old fashion osteoarthritis. Arthritis pain can be treated with anti-inflammatories, bracing, and in severe cases; an ankle fusion of joint replacement. In the end, most people wish they had consulted their doctor for their ankle sprains early on and avoided long term arthritic pain.
In the majority of younger patients with ankle arthritis, their arthritis is usually a secondary effect from too many ankle sprains. Most can relate a twisting type of injury which caused a deep cartilage injury that is often called osteochondritis dissicans. This has been seen to occur with no obvious trauma, but most can relate a history of severe sprain. Over time, the injured cartilage starts to deteriorate, then flake and finally many patients have bone on bone contact which is extremely painful.
Osteochondritis often causes significant pain, swelling and stiffness in the ankle. Patients come in several months after experiencing a bad sprain complaining of continued popping, instability, stiffness and pain. Some complain of severe discomfort, but most relate a chronic annoying ache.
Ankle sprains should not be ignored, because many lead to chronic instability and eventual arthritis. A physical examination by your podiatrist is usually followed by x-rays. If plain film x-rays are negative, and you have had pain for more than 2 months from an ankle sprain; an MRI is indicated to rule out a cartilage injury of the talar dome. This MRI can evaluate the cartilage of the talar dome for obvious flaps and for subchondral injury to the underlying bone. A chip fracture can be quite painful and feel like a clicking every time you move your ankle.
Conservative therapy for osteochondritis includes bracing, physical therapy, anti-inflammatories and rest. Many people do well with just conservative therapy and maintain their joints by working on their proprioception and strength.
Unfortunately, surgical intervention of ankle arthriscopy is often needed to remove the cartilage fragments and place tiny drill holes in the deficit to encourage the formation of fibrocartilage or scar tissue. Severe defects may require cartilage grafting.
So, for all you young sports stars out there: Remember that ignoring multiple ankle sprains and ankle instability is usually a prescription for long term arthritis. Osteochondiritis leads to good old fashion osteoarthritis. Arthritis pain can be treated with anti-inflammatories, bracing, and in severe cases; an ankle fusion of joint replacement. In the end, most people wish they had consulted their doctor for their ankle sprains early on and avoided long term arthritic pain.
Sunday, September 13, 2009
My Big Toe Joint Hurts! The Arthritis You Never Knew!
Have you ever suspected you have arthritis in your big toe joint? It is one of those conditions that slowly creeps up on you. You may be going about your business only to notice that your big toe joint hurts! You may end up limping around for an hour or even a few days and then it disappears only to reappear when you least expect it! What’s up with this? Well, it may be plain ol’arthitis!
Arthritis in the big toe (aka: hallux) joint is known as “Hallux Limitus” or Hallux Rigidus” depending on whether it the motion in your toe is limited or not moving at all (rigid). Basically, how much arthritis you have puts you in either one of those categories. So here it how it works. Over the years, all of your joints wear down to some extent. We start to lose the cartilage, (this is the stuff covering the bones at the joint so the joint can glide smoothly). Once we have worn down enough cartilage, the bones at the joint start making bone on bone contact instead of cartilage on cartilage contact, and this causes pain. This bone on bone rubbing is not as smooth either and it limits the amount of movement at the joint. This is arthritis. As the amount of arthritis in the joint increases, the amount of pain in that joint increases as well!
How does it all start? I tell my patient that simply stubbing your toe, which most of us have done at some point or other, can accelerate the wearing down process. Many times, arthritis in the big toe joint shows up in people with other foot conditions, such as bunions, or flat feet or high arched feet simply because of how our bones line up in the feet. If they are not perfectly aligned, that joint will wear down quicker because it was not meant to work in that position.
What can be done about the pain? Once you have been diagnosed, your podiatrist will be able to tell you just how severe the arthritis in your big toe joint is and treatment will be based on that. Treatment could include anti-inflammatories, custom inserts, physical therapy, shoe alterations, padding, cortisone injections, and in the worst of cases, surgery. That being said, the sooner you see us about your big toe pain, the quicker we can slow down the damage being done to that joint and keep you moving!
Arthritis in the big toe (aka: hallux) joint is known as “Hallux Limitus” or Hallux Rigidus” depending on whether it the motion in your toe is limited or not moving at all (rigid). Basically, how much arthritis you have puts you in either one of those categories. So here it how it works. Over the years, all of your joints wear down to some extent. We start to lose the cartilage, (this is the stuff covering the bones at the joint so the joint can glide smoothly). Once we have worn down enough cartilage, the bones at the joint start making bone on bone contact instead of cartilage on cartilage contact, and this causes pain. This bone on bone rubbing is not as smooth either and it limits the amount of movement at the joint. This is arthritis. As the amount of arthritis in the joint increases, the amount of pain in that joint increases as well!
How does it all start? I tell my patient that simply stubbing your toe, which most of us have done at some point or other, can accelerate the wearing down process. Many times, arthritis in the big toe joint shows up in people with other foot conditions, such as bunions, or flat feet or high arched feet simply because of how our bones line up in the feet. If they are not perfectly aligned, that joint will wear down quicker because it was not meant to work in that position.
What can be done about the pain? Once you have been diagnosed, your podiatrist will be able to tell you just how severe the arthritis in your big toe joint is and treatment will be based on that. Treatment could include anti-inflammatories, custom inserts, physical therapy, shoe alterations, padding, cortisone injections, and in the worst of cases, surgery. That being said, the sooner you see us about your big toe pain, the quicker we can slow down the damage being done to that joint and keep you moving!
Tuesday, September 8, 2009
My toes are starting to curl!!
I first noticed it when I wore a pair of heels the other night(that were maybe a little to pointy). I figured that the 2-3 hours that I wore them wouldn't kill me, but my goodness... By the end of night I had severe pain in my feet, right on the top of my toes.
Today I was looking at my toes and I noticed a small area of redness on the top of my toe right where it is starting to curl. It is sort of hard and painful to the touch, and truthfully a little ugly.. I think it is a corn.
If you are suffering from anything similar to this you may have hammertoes. Hammertoes are a contracture of a joint in the toes, that usually start off flexible and may progress to a more rigid deformity. The more rigid they become the more they will interfere with your ambulation and may lead to corns, or even worse an open sore.
What causes Hammertoes? Hammertoes are a mechanical imbalance of the tendons in the toes. The tendons on top of the foot gain control over other tendons and start to contract and curl your toes. Why does it happen?
1.Can be caused by biomechanics (your foot structure and the way you walk)
2.The wrong shoes (high heels, pointy shoes)
3.Neuromuscular condition
4.Broken toe or trauma to the toe (jamming)
Treatments for Hammertoes:
Treatments usually include accomodative padding, different shoe gear, trimming of corns, anti-inflammatories, injection therapy and surgery. Orthotic devices may also help control abnormal biomechanics.
If you are suffering from any of these symptoms talk to your podiatrist. There are many advances in the treatment of these silly toes!
I first noticed it when I wore a pair of heels the other night(that were maybe a little to pointy). I figured that the 2-3 hours that I wore them wouldn't kill me, but my goodness... By the end of night I had severe pain in my feet, right on the top of my toes.
Today I was looking at my toes and I noticed a small area of redness on the top of my toe right where it is starting to curl. It is sort of hard and painful to the touch, and truthfully a little ugly.. I think it is a corn.
If you are suffering from anything similar to this you may have hammertoes. Hammertoes are a contracture of a joint in the toes, that usually start off flexible and may progress to a more rigid deformity. The more rigid they become the more they will interfere with your ambulation and may lead to corns, or even worse an open sore.
What causes Hammertoes? Hammertoes are a mechanical imbalance of the tendons in the toes. The tendons on top of the foot gain control over other tendons and start to contract and curl your toes. Why does it happen?
1.Can be caused by biomechanics (your foot structure and the way you walk)
2.The wrong shoes (high heels, pointy shoes)
3.Neuromuscular condition
4.Broken toe or trauma to the toe (jamming)
Treatments for Hammertoes:
Treatments usually include accomodative padding, different shoe gear, trimming of corns, anti-inflammatories, injection therapy and surgery. Orthotic devices may also help control abnormal biomechanics.
If you are suffering from any of these symptoms talk to your podiatrist. There are many advances in the treatment of these silly toes!
Wednesday, September 2, 2009
Toenail Disorders Due to Chemotherapy:
I am training to walk the Susan G Komen Breast Cancer Walk Dallas of 2009. During my training I have met a lot of great women. Some are walking as survivors, and others are walking because someone close to them is suffering from the disease, or have lost someone they love.
As you can probably imagine there is a lot of talking during these long training walks. I happen to be a podiatrist, so I commonly have people asking me questions about their feet, proper shoe gear, how to prevent injuries, and most commonly their toenails! Most will say they have either lost toenails or they have turned colors due to the chemotherapy.
Alot of the survivors agree that when undergoing chemo, most of the time they are not warned on what to expect their toenails to begin to look like. No one tells them that their toenails will most likely fall off, turn colors, get thick, have skin attached to them and possibly smell.
When undergoing Chemotherapy the drugs that are commonly used; (Adriamycin, Taxol, 5-Fluorouracil) cause damage and attack the tissue that keeps the toenail in place. This is called onycholysis. It is common for the nail to loose its attachment to the entire nail bed or sometimes only half of the nail bed. Either way when a nail looses its attachment it allows dermatophytes( the bugs that cause fungus) to get under the toenail, also known as onychomycosis.
Tips to Keeping your Toenails Looking There Very Best:
1. Clip toenails straight across and keep them short, this prevents splitting and breakage of the toenail.
2. Keep toenails clean and moisturized. If getting a pedicure make sure all instruments have been sterilized.
3.Cut away any loose cuticles, do not pick or pull at them. This can cause bleeding which can easily lead to an infection.
4. Try to avoid injuries to your toes and toenails, they will bruise easily. Wear wider shoes that have plenty of room in the toe box. Wider shoes will also allow for more circulation to the toes and toenails.
If your nails become infected, inflamed or painful you may need to see a doctor. There are some over the counter treatments that may be fine for your type of infection or you may need a doctor to prescribe a medication to help combat the problem. There are some very advanced treatments that are now available including topical treatments, oral pills and laser treatments.
I am training to walk the Susan G Komen Breast Cancer Walk Dallas of 2009. During my training I have met a lot of great women. Some are walking as survivors, and others are walking because someone close to them is suffering from the disease, or have lost someone they love.
As you can probably imagine there is a lot of talking during these long training walks. I happen to be a podiatrist, so I commonly have people asking me questions about their feet, proper shoe gear, how to prevent injuries, and most commonly their toenails! Most will say they have either lost toenails or they have turned colors due to the chemotherapy.
Alot of the survivors agree that when undergoing chemo, most of the time they are not warned on what to expect their toenails to begin to look like. No one tells them that their toenails will most likely fall off, turn colors, get thick, have skin attached to them and possibly smell.
When undergoing Chemotherapy the drugs that are commonly used; (Adriamycin, Taxol, 5-Fluorouracil) cause damage and attack the tissue that keeps the toenail in place. This is called onycholysis. It is common for the nail to loose its attachment to the entire nail bed or sometimes only half of the nail bed. Either way when a nail looses its attachment it allows dermatophytes( the bugs that cause fungus) to get under the toenail, also known as onychomycosis.
Tips to Keeping your Toenails Looking There Very Best:
1. Clip toenails straight across and keep them short, this prevents splitting and breakage of the toenail.
2. Keep toenails clean and moisturized. If getting a pedicure make sure all instruments have been sterilized.
3.Cut away any loose cuticles, do not pick or pull at them. This can cause bleeding which can easily lead to an infection.
4. Try to avoid injuries to your toes and toenails, they will bruise easily. Wear wider shoes that have plenty of room in the toe box. Wider shoes will also allow for more circulation to the toes and toenails.
If your nails become infected, inflamed or painful you may need to see a doctor. There are some over the counter treatments that may be fine for your type of infection or you may need a doctor to prescribe a medication to help combat the problem. There are some very advanced treatments that are now available including topical treatments, oral pills and laser treatments.
Tuesday, September 1, 2009
“Mom, My Heels Hurt!”
It is that time of year again. Returning to school and those extra curricular activities. Kids are excited about sports and band practice, but this sudden increase in activity can cause them to have heel pain. Pediatric heel pain is nothing to ignore. It is not your typical adult heel pain caused by plantar fasciitis and will not go away with advil alone. It can be excruciating for some children to the point they cannot walk. So what is it really and why does it happen?
Calcaneal apophysitis is the medical term for inflammation of the growth plate in the heel caused by the pull of the plantar fascia below it and the Achilles tendon above it. As we grow, the bones in the legs get longer, but the muscles and tendons have to stretch to grow with them. If these structures are tight and have not reached the same length as the bones, then they pull much harder on the growth plates. This causes significant pain that usually occurs after activity and improves with rest. Other symptoms including swelling of the heels, pain with pressure and increased warmth.
Treating pediatric heel pain early is important. In our office, youf child will be fully evaluated including xrays to make sure that the growth plate is normal and the pain is not caused from other reasons like a stress fracture. Rest, ice and stretching are key factors in treating heel pain in children. Appropriate shoe gear, orthotics and physical therapy will also improve their pain and reduce recurrence. In severe cases, complete immobilization may be necessary.
If your child is complaining of heel pain, don’t ignore it. This pain can prevent them from participating in the activities they enjoy. At Foot and Ankle Associates of North Texas, we are here to get your children back in the game.
Calcaneal apophysitis is the medical term for inflammation of the growth plate in the heel caused by the pull of the plantar fascia below it and the Achilles tendon above it. As we grow, the bones in the legs get longer, but the muscles and tendons have to stretch to grow with them. If these structures are tight and have not reached the same length as the bones, then they pull much harder on the growth plates. This causes significant pain that usually occurs after activity and improves with rest. Other symptoms including swelling of the heels, pain with pressure and increased warmth.
Treating pediatric heel pain early is important. In our office, youf child will be fully evaluated including xrays to make sure that the growth plate is normal and the pain is not caused from other reasons like a stress fracture. Rest, ice and stretching are key factors in treating heel pain in children. Appropriate shoe gear, orthotics and physical therapy will also improve their pain and reduce recurrence. In severe cases, complete immobilization may be necessary.
If your child is complaining of heel pain, don’t ignore it. This pain can prevent them from participating in the activities they enjoy. At Foot and Ankle Associates of North Texas, we are here to get your children back in the game.
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