Acute Vs. Chronic Heel Pain: New Treatments Available

Dr Marybeth Crane discusses acute versus chronic heel pain in this informative video. It is important to understand the difference between acute plantar fasciitis and chronic plantar fascists and their treatments.

Foot Check-Up- What Am I Looking For?

Last night I checked my feet. I don’t know why. They do not hurt. But I gave them a good look over on the bottoms, tops, heels, in between my toes. A foot check-up!  It has been a while since I’ve done that! I see and help so many feet during the day in my occupation, and I am very good about wearing good shoes, but checking my feel regularly? Admittedly, I have not! We are all guilty of ignoring our feet unless they make us pay attention to them!

As I was looking, I realized many of you out there reading this may now be thinking about doing so yourselves, but have no clue what you are looking for. And if you found something, would it be something you would need me to look at? I thought I might share with you a list of things you may want to see your podiatrist for!

 Looking at those feet, notice the nails. Are they yellowish or opaque? Are they brittle? You may have a nail fungus. A fungus that has taken root in your nail is very rarely rid of with over the counter topical product (and that is assuming you are willing to use that product consistently for at least 8 months!)

 Do you have a dark stripe or splotch under the nail that has not grown out with the growth of the nail? Do you have a mole that has grown, darkened or become irregular? Or maybe a mole has developed that was not there before? Or maybe there is just a strange looking discoloration you did not have before. Believe it or not, skin cancer can happen on the foot or under the nail! If there is any question, have it checked out!

 Look in between the toes. Is it scaly? Is it red? You may have athletes foot (a form of fungus!) or worse, a bacterial infection! Fungus like to start here where it is especially dark and moist between the toes before spreading the sides or bottom of the feet! What is the quality of the skin on the sides and bottom? When fungus gets a hold, feet or nails, it is tough to shake off quickly. Scratching can introduce bacteria into those areas and no fungal cream out there will make bacteria go away! Get to it before it starts letting you know it’s around!

 Look for areas of the skin that look thicker. Is it a pin point callus, a broad callus or is it a wart? Or could you have possibly stepped on something? Sometimes it is hard to tell. They are all treated differently, but one thing is common for all. They all do worse in the long run if they are picked at with whatever contraption you may have gotten a hold of in the bathroom!

 Do you have what looks like a mini grand canyon invading your heels? We call these “fissures”. This condition is hereditary and does not go away with simple lotions. Worse, the deeper the canyons get, the greater the chance of you developing a bacterial infection in the deepest grooves. Treatment is advised for fissures before they become painful.

 Feel the bottoms of your feet with the pressure of a massage. (Not a bad idea in either case!) Do you feel any deep lumps? You should not have any. If you do, let us take a look and feel. It is good to get what we call a “baseline” or early measurement. Getting a look and feel and measuring these lumps will give us the best information on whether this lump something that needs to come out or whether it just needs to be monitored.

Are you checking yet? If you can’t see the bottoms, use a mirror or have someone else take a look! Don’t have either option? We won’t retire for a while! Come out for visit!

Is Bunion Surgery Worth It?

Is Bunion Surgery Worth It?

Interesting question that can be answered yes and no.

Yes, if you have pain every day in your foot around the bunion and it is keeping you from doing the things you want to do.

No, if you just think the bunion is ugly and it is keeping you from wearing cute shoes.

In general, surgery for bunions is only recommended when pain from the bunion prevents a patient from wearing normal shoes and performing their normal daily activities. If your bunions only hurt when you are wearing pointy toed, high heeled shoes; surgery is not your best option. You should try padding, wider shoes, orthotics and injections; as well as much more sensible wider toe box, lower heeled shoes.

There is a common misconception that surgical treatments for a bunion are better and quicker than non-surgical treatments. Unfortunately, patients who rush into surgery may have unrealistic expectations, and may be unsatisfied with surgery.

Patients considering bunion surgery should understand the following about surgical treatments of bunions and also dispel some common misperceptions or myths about bunion surgery:

Myth #1: It is a common myth that bunion surgery is often unsuccessful or “botched”. This is simply not true. Almost 95% of patient surveyed 6 months after bunion surgery would not only do it again, but would recommend it to their friends and family. That’s a pretty good success rate. Patients must have realistic expectations. Bunion surgery can be helpful at relieving pain, but patients should not expect to have "perfectly normal" feet after surgery. And surgery cannot make your foot fit into a 4 inch heeled shoe comfortably.

Myth #2: Bunion surgery is extremely painful. Again, simply not true. Bunion surgery is not particularly "more" painful than other surgeries.  There is pain after surgery, but most patients only require narcotic pain medication for a few days after surgery then use anti-inflammatories to control their discomfort and swelling. Foot surgery, in general, can lend itself to increased pain post-operatively because the foot is below the level of the heart and blood can rush to the area, causing a throbbing feeling. This can be well controlled with a post-operative pain management program.

Myth #3: Bunions come back even after surgery. Again, not true. A majority of patients are satisfied with their outcome after bunion surgery. Recurrence is possible, but not particularly likely. And, return of a bunion is not necessarily a complication, but something that can happen over time. Some patients have excessive motion in the foot that may predispose them to recurrence. This is why functional foot orthotics are needed in many patients post0operatively to control foot function. Another possible reason for recurrence occurs when a procedure that was performed did not best suit the severity of the particular bunion -- so it's important to have the surgery tailored for your particular bunion. Discuss this with your surgeon or get another opinion prior to surgery.

Myth #4: Bunion Surgery = cast and crutches for months. While this was true years ago, more modern techniques have allowed surgeons to mobilize patients quicker. Mild bunions typically involve walking in short walking boot cast for one month, then a sneaker for another month. Surgeons consider casting with crutches with larger bunions because setting the bones is more complex. Some surgeons have moved away from bone cuts and instead perform a fusion procedure that allows for realignment of the entire deviated bone. This fusion procedure is called the Lapidus Bunionectomy, and contemporary approaches allow for early protected walking at four to six weeks postoperatively. Recent technological advances in medical implant devices have also helped surgeons modify their techniques to get patients moving quicker.

Myth #5: You have to be off work. This, again, is simply not true, and a function of the demands of your workplace. A patient can return to a sedentary desk job within a week of the surgery, and varies based on surgeon protocol and type of bunion surgery performed. Jobs that require excessive walking, standing and physical activity may require a medical leave of absence -- which can be up to two to three months depending on healing and job requirements. Getting around can be difficult and driving may be off limits if you have your right foot operated on and/or drive a manual. Job demands of a pilot certainly differ than those of a secretary.

Myth #6: Don't fix a bunion unless extremely painful. The concern with surgically correcting a non-painful bunion is that the surgery can result in longstanding post-operative pain that may not have been there prior. The old rule-of-thumb, if it ain’t broke, don’t fix it. However, people do have surgery for non-painful bunions if the bunion interferes with activity, continues to become larger, or if they have difficulty wearing certain shoes. Surgeons strongly prefer that patients have a painful bunion before they consider surgery. Fortunately, pain is the most common reason people seek treatment.

Myth #7: Bunion surgery results in ugly scars: Surgical healing is part of the process with any surgery, and bunion surgery is no different. Incisions can be minimized, or alternate surgical approaches may be used to hide surgical scars. Bunion incisions are usually located on the top of the foot and technique varies based on surgeon. A surgeon may perform a plastic surgery-type closure to keep scaring minimum. Decreasing swelling, avoiding infection in the postoperative period, and scar cream can also minimize scars.

Bunion surgery, just like any surgery, has its share of myths. Basically, because not all bunions are treated the same, information that may apply to someone with a large bunion may not apply to someone with a small bunion. Take the time to discuss your reservations and alternatives with your surgeon. Often you will find that myths like the 7 discussed are just simply not true. 

The majority of patients, having bunion surgery for the right reasons, end up with a good to excellent outcome and would tell you that bunion surgery is definitely worth it!

Yankees Derek Jeter Out For the Season With an Ankle Fracture

New York Yankees shortstop and captain, Derek Jeter will miss the rest of the playoffs after suffering a fractured left ankle while trying to make a play in the 12th inning of Saturday night's 6-4 loss to the Detroit Tigers in Game 1 of the American League Championship Series.

Jeter walked off the field with the help of Yankees manager Joe Girardi and the trainer. X-rays revealed an ankle fracture. This will take at least 2-3 months to heal and then rehab. He is done for the season. 

Ankle fractures can be tricky and depending on the angle and separation of the fragment, he could require surgery to put the pieces back together so they can heal in the correct position.

Any time you fall down or twist your ankle, an x-ray should be taken. Yes, you can walk on some ankle fractures and delayed diagnosis can lead to a much more complicated recovery and even long term disability.

Got ankle pain? Contact us for an appointment. For more information on ankle fractures, click here.

Got Bunion Pain?

Do you have pain in your bunions? Are they slowing you down? Don't be afraid to go to the podiatrist. Help is on the way. Does the conversation with your family sound like this couple?

Stem Cells Now Used to Treat Foot and Ankle Pain

For a very long time, I have been watching the stem cell research and debates and patiently (not really) waiting for a useful application in the foot and ankle.  Whether you are for or against this topic, this blog is not a debate on its use.  My blog today is to tell you about the patients I have used it on and their success.

I began to use it in my practice last December with skeptical ideas on how successful it could be.  I've been pleasantly surprised at the results.  Let's start with what the stem cells are.

I use AmnioMatrix.  This is amniotic fluid taken from mothers who have consented to have the fluid removed during C-sections.  There is absolutely no harm to mom or baby and this is not done prior to birth.  The fluid is then cryopreserved with no additives keeping the cells live for use when they are thawed and injected.  So why these cells?  Their job in the baby making process is to protect the fetus and help with development.  When you hear the term "my water broke", that's amniotic fluid.  When placed in an adult to the site of an injury or chronic pain area, these cells recognize what is missing or not normal and begin a healing process.  If you want to read more of about this, Applied Biologics will answer a lot of questions.

What have I used it for so far? Plantar fasciitis, Achilles tendonitis, neuromas, non-healing fractures, non-healing ulcers

So let's talk about some patients that have benefitted from this product.

The first one is Amy.  She is a very active 45 y/o mom and business professional who began having pain in her Achilles tendon after a long run.  This progressed to a large knot on the back of her Achilles tendon above where it inserts on the back of her heel.  We call this Achilles tendonitis or tendonosis.  She attempted resting, icing, physical therapy, good shoes.  No steroid injections are performed in a tendon area because this can cause rupture of the tendon.  I sent her for an MRI which came back as small micro tears in the tendon.  This means the tendon isn't completely torn, just very tiny tears causing the swelling and pain.  During all of this, she was not able to work out and her mood had dropped significantly at home and work.  We talked about her options and in the past, surgery to clean out the tendon was her only resort.  She decided to try the amniomatrix instead.

This did require surgery, but minimally invasive.  I made a very small incision on the side of the bump on her Achilles tendon.  I opened the protective sheath around the tendon and made several small holes in the bump called a microtenotomy.  This allowed a portal for the stem cells to reach inside the tendon.  I injected the AmnioMatrix stem cells all around the tendon, then carefully closed the sheath and skin.

She did very well during her recovery.  She had no pain at post op day 5 and never really had swelling or bruising.  She used her walking boot for 3 weeks and was able to walk without crutches at post op day 3. After crutches, she wore tennis shoes for 2 months and made sure not to do a lot of barefoot walking.  She started a light exercise program at week 4 and has progressed back to running at her normal pace with pain.  And her mood is dramatically better.

The next patient I want to talk about is Kathleen.  She is a 50 y/o financial advisor who suffered a fracture of one of her sesamoid bones.  The sesamoids are 2 small bones that lie under your big toe joint and help propel you forward when you walk.  I treated her like I would any fracture by placing her in a walking boot to reduce pressure and pain and ice.  Normally bone heals at 4-6 weeks.  After 3 months, she had no improvement in pain and X-rays showed the bone was not healing.  I ordered an MRI which showed the fracture without surrounding edema which means it had stopped healing.  Normally, the next step is surgery to remove the injured sesamoid.  But she was not happy with the possibility that her big toe would drift after surgery.  So we discussed amniomatrix.

This also required a small surgery.  Under anesthesia, I used a large pin and drilled several holes through the fracture line and the bone.  This was done under a live X-ray in the OR.  I then injected the entire area with AmnioMatrix.  Post op she wore her boot for 6 weeks.  Was pain free at week 2, could move her toe without pain at week 3.  She started wearing tennis shoes at 6 weeks and began gradual increase in her activity.  She remains pain free and is doing very well in regular shoes.

I've got lots of stories like the 2 above and over the next several weeks will be sharing those with you so check back often.  If any of these stories make you say "Hey, that's me", come see me!

So You Think a Broken Toe Isn't Serious?

So you think a broken toes is no big deal? Just last week I had a runner come in 6 months after breaking her 5th toe by kicking a shopping cart. She didn't have it x-rayed because in her words, "I didn't think there was anything you could do for a broken toe".

Here she was six months later because not only was she having a hard time fitting her still swollen toe in a high heeled shoe for work, but now it was bothering her in her running shoes. Pain when running will always bring a runner in the office!

What had happened is that she had an oblique fracture of her proximal phalanx which was displaced and healed in an abnormal position. In English, she broke her 5th toe and the bone healed crooked making a big lump that rubbed on her 4th toe causing a blister then a large corn in between the toes.

These types of corns known as "heloma molle" are very painful and can often get infected. In a diabetic or other patients with poor immune systems, these can even lead to a toe amputation! In my runner's case, she was treated conservatively with a silicone toe sleeve to pad it off until she had time to have an arthroplasty of the toe which is a surgery that removes part of the poorly healed bone and alleviates the rubbing. This surgery could have been prevented by seeking help earlier as soon as she broke her toe. 

Take home message: if you think you broke your toe, have it x-rayed and see your favorite podiatrist. They may tell you it is broken, but straight; or they may need to numb it up and pull it back into the correct position, so you can avoid surgery that will keep you laid up for weeks!