Monday, April 28, 2014

What you should know about the "Rheumatoid" foot

Rheumatoid arthritis is a chronic inflammatory disorder that affects at least 1.3 million Americans. It is also considered an autoimmune disorder, which means that the body's own immune system attacks its own body tissues. In addition to causing joint problems, Rheumatoid arthritis can affect other organs of the body such as the skin, eyes, lungs, and blood vessels. The treatment requires long-term medications to control "flare-ups" and prevent progressive autoimmune damage to joints throughout the body. It also often manifests in the foot and ankle.

Manifestation of Rheumatoid arthritis on the small joints of the hand. Note the deviation of the digitis and contractures

Manifestation of Rheumatoid arthritis on the joints of the foot. Note dislocation and contracture of the toes.

Here are some manifestations of Rheumatoid Arthirtis in the foot and ankle:
  • Joint space loss 
  • Persistent swelling 
  • Dislocations of lesser toe joints 
  • Dislocation/Deviation of the larger joints in the foot and ankle 
  • Deviation and contracture of toes 
  • Destruction of Joint capsules and supporting soft-tissue structures (ligaments) 
  • Pain 
  • Foot/ankle ulcerations or skin break-down 
Treatments can vary from non-operative to operative but controlling the inflammatory process is essential. This can be done with local anti-inflammatory medications to control the acute "flare-ups" and ultimately suppressive regimen to control the process long-term. When it comes to foot and ankle treatments, non-operative options include but are not limited to: 
  • Custom-molded orthotics or bracing - controls motion of the joints, especially if inflammed and in doing so, prevents pain and swelling 
  • Pads - Toe pads or "bunion" pads can be beneficial in preventing rubbing and irritation 
  • Physical therapy - Strengthen weak muscle groups and stretch tight tendon contractures 
  • Custom shoes - Extra-depth shoes provide protective insoles which can accommodate for contracted joints 
  • Surgical management of the Rheumatoid foot accomplishes the following objectives: 
  • Relieve inflammatory joints from pain and swelling 
  • Re-align the foot/ankle architecture 
  • Provide stability and a functional foot 
  • Prevent breakdown of the skin and ulcerations 
Surgery can be accomplished using various techniques and options that include but are not limited to:
  • Arthrodesis - Fusing of inflammed joints to prevent motion and pain. This is often seen at the great toe joint and sometimes the ankle. Screws, plates, and metallic wires are using to accomplish this fusion. 
  • Partial resection of metatarsal bones - This can help decompress contracted toes 
  • Lesser toe tendon balancing - in doing so, we can eliminate the painful contractures of the lesser toes 
  • Joint replacement - Typically reserved for the Ankle joint 

Although surgery on the Rheumatoid patient brings a lot of functional benefits, it is also important to consider the associated risk factors including but not limited to:
  • Infections - Rheumatoid patients are prone to infections secondary to long-term steroid use, which can cause an immunosuppressed state 
  • Chronic Regional Pain Syndrome 
  • Recurrence of deformity 
  • Inflammation and pain 
If you have any questions about management of the Rheumatoid foot or ankle, then consult with your foot and ankle specialist.

Thursday, April 24, 2014

Pregnancy and Varicose Veins

Varicose veins during pregnancy are one of the many body changes a woman goes through during this wonderful time in her life. Unfortunately, there are some not-so-wonderful things that happen to a pregnant body. However, the good thing about varicose veins during pregnancy is that they are usually not harmful and they will most likely disappear after giving birth. In some cases, varicose veins might cause some discomfort, itching, or pain, but for the most part, the main complaint among pregnant mothers is that they don’t like the way they look.

What are varicose veins? Varicose veins are blood vessels that bulge out and show through the skin because they are green, blue, or purple. The reason that pregnancy sometimes causes varicose or even smaller spider veins to show is because of the extra blood produced during pregnancy combined with weight gain. The pressure on the legs that are working against gravity to push the blood back to the heart causes varicose veins to emerge. The podiatrists at West Georgia Podiatry can help expectant mothers prevent or mitigate varicose veins during pregnancy and also provide consultation on how to get rid of varicose veins that do not disappear on their own within a few months after giving birth.

What Can You Do to Prevent & Treat Varicose Veins During Pregnancy?

Chances are that any varicose veins that appear during pregnancy will fade away within a few months after giving birth. However, there are still some things that expectant mothers can do to prevent or at least lessen the appearance of varicose veins.
Exercise is important during pregnancy for a number of great reasons, one of which is that keeping the blood circulating helps reduce chances of varicose veins. Make sure to consult your doctor about what types of exercises are best for you.
In addition to exercise, keep your blood circulating by elevating your feet when sitting and get up often to walk around when you’ve been sitting for long periods of time.
Another way to keep up circulation flow is by sleeping on your left side instead of your right side.
Wear support tights or support stockings, but make sure that all of your other clothes are not too tight or restricting. There are also specially made compression stockings for varicose veins.
Avoid heavy lifting or straining.
Keep weight gain to a minimum.
In addition to a healthy diet, make sure to get the recommended daily allowance of vitamin C, which specifically helps vein health.

Treatment Options for Varicose or Spider Veins that Remain After Pregnancy

In some cases, the varicose veins do not completely disappear after pregnancy or small spider veins might remain. If this happens to you, consult with our podiatrists at West Georgia Podiatry for their expert advice in this area. Treatment options can include laser spider vein removal. These treatments help to get rid of varicose veins and are just an appointment away.

West Georgia Podiatry Doctors Perform Varicose Vein and Spider Vein Treatment

We understand the body changes after pregnancy and that some veins might still present a problem for patients. Our doctors are always available to consult with you and help weigh the pros and cons of the different vein treatment options and help you determine which varicose vein remedy is right for you.

Wednesday, March 19, 2014

Secrets of Recurring Heel Pain

Many patients are becoming even more active with age, and as this new generation of elderly patients become our community's senior citizens we are finding out more often that you are only as young as you feel. With this, there are different aches and pains, and they are more common and can be restricting towards maintaining this level of leisure. Above all other pains common to the foot and ankle, heel pain is by far the most common. Sometimes, we will be a 3rd and 4th opinion to attempt to remove this nuisance from our patient's feet. Most often heel pain is treated by cortisone injections, physical therapy, weight loss, and orthotics. 

But what about the patients who have been there and done that?

There are few treatments that are more promising in the field of heel pain management with more potential than the

Extra Corporal Shockwave Therapy for very tough heel pain. A good overview of the proposed mechanism for how this works involves using devices that generate pulses of high-pressure sound that travel through the skin and yeild natural repair from the tissues and increased blood flow networks to damaged tissues. 

For reasons that are not fully understood, soft tissue and bone that are subjected to these pulses of high-pressure energy heal back stronger and without causing further damage to the tissues like repeated cortisone injections may do. 

The FDA has approved the use of some ESWT machines for heel pain and tennis elbow. ESWT devices evolved from lithotripters (a.k.a. kidney stone shock wave machines). The discovery of the beneficial effects of ESWT came as German researchers were trying to determine what type of high-pressure pulses could be sent through the body to disintegrate kidney stones without causing harm to surrounding tissue. In laboratory animals and humans, it was discovered (with some surprise) that surrounding tissue would often heal back stronger and this applies well to our topic of heel pain. 

Physical therapists use ultrasound machines that warm internal tissue by high frequency sound waves, but the ESWT machines send higher-energy pulses 2 or 3 times per second rather than continuous lower-energy waves. Electricity is not sent into the body. It may take as long as 5 months to see the full benefit of an ESWT treatment. The beneficial effect of the high-pressure waves may be from the growth of new blood vessels ("neovascularization") in small cavities that are created by the pulses. New blood vessels to an area of tissue would promote healing either directly or indirectly by providing additional growth factors to the area of concern by way of new vascular channels.

Some studies have even shown this therapy to be equivalent to a fasciotomy, which is an invasive procedure that involves an incision to sever the medial fibers of the fascia for reduced pressure and tension on the inferior heel bone. This means that you can get equivalent results without the complications of a minor procedure. We can provide ESWT that has benefits that have been shown to work well on difficult heel pain. This can be beneficial to our patients, and if you are limping in the AM, or have trouble walking after a brief rest from activity because your heel is holding you back, you should consider a consultation with one of our doctors.

Achilles Pain ?

1) NOT all posterior heel pains are tendon problems.

We will provide a thorough examination, which includes radio graphs, and clinical exam with history taking to provide the best possible outcome for your pain. There are several other structures which are present and could be treated in a different manner than any straight forward Achilles tendinitis. Noted above, there is a bursa which is present here and can often be the root cause of pain secondary to bursitis. This is treated differently than Achilles tendinitis. This may also require MRI to determine how much of the inflammation is related to bone versus soft tissue. Additionally, and more rarely, a stress fracture can cause this pain in the calcaneus. This is not common but we check for this as well.

2) Tendon tears do NOT always require surgery.

After clinical examination and proper staging/grading of the extent of the tear, we have had success in treating Achilles partial tears and even ruptures non-surgically in select patient populations. We have a variety of techniques at our disposal in order to facilitate the healing process if surgery is not indicated. In the case of chronic tears there are several nonsurgical treatments that work, particularly PRP injections, High energy shock-wave treatments, and even physical therapy with anti inflammatory ultrasound.

3) Bone spurs are NOT always relevant.

Often times patients will state that they "Have had a spur in the past but it went away". Usually any bone protuberance which is either palpable or visible on a plan radio-graph or MRI will NOT go away spontaneously ever and always if indicated will need resection if it is the root cause of the symptoms. In most cases the spur is not the root cause of the symptoms, and is not required to remove it, but there are far too often very large spurs which are not even symptomatic that are visible on X-ray examinations in many of our patients, therefore backing up further the concept that bone spurs are not always the real problem.

Bio-mechanically a bone spur will exist in areas of either repeated chronic trauma, or areas of chronic taut insertions. Rarely is this an isolated tumor of bone, and that being said, it is often not necessary to remove the bone spur.

Friday, January 10, 2014

What you need to know about your kids flatfeet?

Pediatric (child) flatfeet can be seen at an early age and progressively affect growth, posture, and activity level if left neglected.  Literature and studies have shown that flatfeet in children are progressive and can cause debilitating effects if left, untreated.

Here are 5 must-know facts about children's flatfeet:
  1. Genetics are the primary cause - although, there are different etiologies that can result in flatfeet the number one source is typically genetics
  2. Foot orthotics are important - The function of those devices is to re-align the foot position and thus better align the other lower extremity joints (knees, hips) and overall posture
  3. "Growing pains" is a myth - Very often, do we hear of this term but in reality if your child is suffering from persistent pain to the foot/ankle with notable "limps" and decrease in activity levels, then they need to be examined more carefully.
  4. Physical therapy is paramount in treatment - the role of therapy is to stretch the tight calf muscles and strengthen the weaker tendons/muscles, which are affected by the flatfoot deformity.
  5. Surgery can help! - Surgery on the pediatric population has shown very good to excellent results in a variety of scientific studies and literature.  The results are predictable and kids have a better long-term function which can avoid them from having debilitating arthritis, knee/hip pain as they get older.
Pre-operative clinical photograph of a child's feet before undergoing flatfoot surgery
Postoperative photograph of the same patient 4 months after surgery.  Note improvement in foot and leg position on the right.
If you have any questions about pediatric flatfeet, their treatment, and surgeries then please consult with your foot and ankle specialist.
Turf Toe

The simplest definition of turf toe is that it is a sprain of the main joint of the big toe. It happens when the toe is forcibly bent up into hyperextension, such as when pushing off into a sprint and having the toe get stuck flat on the ground.
Sprains of the big toe joint became especially prevalent in American football players after artificial turf became more common on playing fields - hence the term "turf toe." Artificial turf is a harder surface than grass and does not have much "give" when forces are placed on it.
Although often associated with football, turf toe occurs in a wide range of sports and activities.

The typical position of the foot when a turf toe injury occurs.

The big toe is made up of two joints. The largest of the two is the metatarsophalangeal joint (MTP), where the first long bone of the foot (metatarsal) meets the first bone of the toe (phalanx). In turf toe, the MTP joint is injured.

The MTP joint is the large joint closest to the base of the big toe.

The joint is surrounded by important structures that hold it in place and prevent it from dislocating. Together these structures are referred to as the "plantar complex."
Plantar plate. This thick, fibrous tissue under the MTP joint prevents the big toe from bending too far (dorsiflexion).
Collateral ligaments. Located on each side of the big toe, collateral ligaments connect the phalanx bone to the metatarsal and prevent the toe from going too far side-to-side.
Flexor hallucis brevis. This tendon runs under the first metatarsal bone and attaches to the phalanx. It provides strength and stability to the big toe during push-off motions.
Sesamoids. These two small bones are enveloped in the flexor hallucis tendon, and help it to move more easily. In addition, the sesamoids provide stability to the MTP joint by helping to bear weight placed on the forefoot.

Several structures work together to protect and stabilize the MTP joint.

The term "turf toe" refers to an injury of any soft tissue structure in the plantar complex, such as the plantar plate or a collateral ligament. These injuries can vary in severity — from stretching of the soft tissue to partial tearing, and even total dislocation of the MTP joint.
To help them plan treatment for turf toe, doctors grade the injuries from 1 to 3 - mild to severe.
Grade 1. The plantar complex has been stretched causing pin-point tenderness and slight swelling.
Grade 2. A partial tearing of the plantar complex causes more widespread tenderness, moderate swelling, and bruising. Movement of the toe is limited and painful.
Grade 3. The plantar complex is completely torn causing severe tenderness, severe swelling, and bruising. It is difficult and painful to move the big toe.

We have treated this injury on and off over the years with similar therapy. Rarely does this require surgery, and there is sparse literature which can be referenced to delineate whether grade 1 and grade 3 injuries are specifically nonsurgical or surgical. We have used a combination of PRP injections with hallux extension BK casting for this injury and have found good success. This is a non surgical approach and has had with it some good short term success. But this may still be a devastating injury for most athletes. (Even notable pros such as Deion Sanders, have had career ending versions of this injury).

Flatfeet could slow you down

How is this possible?
The results conducted by the American Podiatric Medical Association concluded that a staggering 73 percent of people asked said that they are suffering from foot pain.

The question is: why has foot pain become one of the most common complaints in the examination room?

For many people, this problem can be caused by one of the following: the kinds of shoes they wear, what activities they participate in, or how their feet are formed. Wearing poorly-fitting shoes can turn minor problems into major ones. People who engage in athletic activities are another segment of the population that are mostly affected by foot pain. Factors such as fallen arches, overpronation, and poor support can all be contributing factors to lower extremity pain. Parents can also be the cause of foot-related problems, because genetics play a role how the foot was formed in the womb. This can enhance the likelihood that someone will suffer from an array of painful foot conditions.

The Mechanics of the Foot
Flat feet can cause abnormal rotation of the feet when walking or running. Our feet handle balance, stability, and bear the weight of the body. The parts of the foot that help to keep the foot in harmony with the body include the arch, heel, tarsals and meta-tarsals. The arch provides stability by the following structures: the tendons, ligaments, and muscles. Pain can result from raised arches or abnormally-low arches, which can cause the foot to rotate abnormally. With high arches, the body’s weight is abnormally emphasized on the outer edge of the foot (oversupination). Conversely, overpronation happens with fallen arches because the weight of the body is concentrated on the inside of the foot, causing the ankles to roll inward .

Serious Foot Issues May Occur with Flat Feet A quick way to see if fallen arches or high arches are an issue is to find a good area where a foot impression can be made, such as on concrete. Immerse on foot in cold water and then stamp your foot onto the dry surface. Then, lift the foot off the ground and see the impression that is left by the foot. A flat foot with overpronation will leave a complete mark where the entire foot has touched the ground. A high arch will leave just a part of the ball of the foot’s outside portion, and heel of the foot. Either of these arch conditions can cause painful bony growths in the heel because the foot has to deal with too much pressure in places it is not intended to handle.

Orthotics Provide Effective Relief for Therapy For Plantar Fasciitis
People suffering from fallen arches, heel spurs, or who need plantar fasciitis treatment can get relief by using the best orthotics available in their shoes. They offer the needed support to fix the weak structures in the foot, such as those that make up the arch. They also offer cushioning in areas where too much pressure occurs, such as in the heel or ball of the foot. Orthotics are available in an array of sizes and types and are made to keep up with anyone’s activity level.

Make an appointment today for more information.