Diabetic peripheral neuropathy surgery – how successful is it?

I find it interesting that there’s really no one, single agreed upon theory to explain the onset of diabetic peripheral neuropathy (DPN).  One of the many theories describes intraneural edema, or swelling within the nerve.  Swelling within the nerve is caused by a concentration of blood sugar in the nerve that creates an osmotic gradient, pulling fluid into the nerve.  This condition is particularly problematic at sites where a nerve rounds an anatomical corner where it , may sustain physical irritation from movement of adjacent soft tissue and bone.  Symptoms of intraneural edema include tingling and burning of the feet and legs.  This condition is often called crush syndrome.

As a lower extremity surgeon, I’m often asked whether surgery is a method by which diabetic peripheral neuropathy can be treated.  In all too many cases, the answer is no.  But in some cases, if we think about the theory above, we actually can treat diabetic peripheral neuropathy with a  surgical procedure.  This surgery is called external neurolysis.  External neurolysis is a technique whereby the surgeon releases the nerve from any entrapment.  Carpal tunnel is a good example of external neurolysis.  Although carpal tunnel isn’t traditionally performed to treat DPN, carpal tunnel surgery is the same technique where the outer (external) portion of the nerve is freed form any entrapment.

There are three location in the leg where entrapments of the nerves can commonly occur.  Not all cases require that all three sites are treated.  We refer to the number of affected sites by calling the condition, single crush syndrome (1 site), double crush syndrome (2 sites) or triple crush syndrome (3 sites).

Most importantly we have to ask: what is the success rate of external neurolysis for the treatment of diabetic peripheral neuropathy?  I tell my patients to hope for 60% improvement.  Is that too low?  Maybe.  But I want to build realistic expectations for these surgeries.  But if I can help a patient to feel their feet again, I may indeed be helping to save their limb.  When diabetic patients lose that ability to feel the floor, we call that ‘loss of protective sensation’ or LOPS.  Feeling is key to avoiding infections and ulcerations of the feet.  And restoring sensation can make a huge difference.

So is surgery indicated for the treatment of DPN?  Maybe.  You might want to sit and have a long talk with your doctor first to see if it may be indicated for you.

Jeffrey A. Oster, DPM
Medical Director
Myfootshop.com

What’s so important about heel lifts? (part 3 of 3: Achilles tendonitis)

Achilles tendonitis can actually be one of several conditions.  Each of these forms of Achilles tendonitis can be improved and even healed with the use of a heel lift.  Let’s talk a little bit about Achilles tendonitis and see how a heel lift can help.

Walking and running can be described in very simple terms.  When our mind decides to move in a specific direction, the mind sends a signal to the calf.  The calf fires and delivers a force to the ball of the foot.  The action created at the ball of the foot is to lift us and initiate a bit of a forward fall.  We break that fall by putting our opposite foot forward and the whole process begins again, lifting the body and perpetuating the forward fall.  The calf initiates this action by delivering force through the single strongest tendon in our body, the Achilles tendon.  Therefore the Achilles is put under stress again and again throughout the day.  In most cases, the Achilles can mend over a period of 24 hours.  But in some cases, chronic loading of the Achilles will result in an inflammatory change called Achilles tendonitis. 

So if we know that Achilles tendonitis is the result of repetitive load, common sense would dictate that we need to find a way to decrease that load applied to the tendon.  Our choice is to either decrease the number of steps we take in a day or to decrease the amount of load applied to the heel with each step.  And that’s the beauty of a heel lift.  By elevating the heel, we weaken the load applied to the Achilles tendon with each step.  So rather than limiting our activities, we can still be active and heal with the use of a lift.

Jeffrey A. Oster, DPM
Medical Director
Myfootshop.com

What’s so important about heel lifts? (part 2 of 3: plantar fasciitis)

I had an interesting conversation with a patient this morning about plantar fasciitis.  The patient had classic signs of plantar fasciitis that included pain upon initial weight bearing and relief of pain with rest.  In her research on the Internet, she had found that most informational sources stressed support of the arch with an arch support.  “I was ready to spend over a hundred dollars at a foot care web site but thought I better check with you first.”  And I think my patient was very surprised to hear from me that plantar fasciitis had nothing to do with arch support.  It has everything to do with the height of the heel.

In part one of this series on heel lifts, we talked a bit about the mechanical forces that are generated by the calf and how those forces are distributed in the foot.  A fine balance exists in the leg, ankle and foot that performs well in young patients, but tends to develop problems as we age.  You see, the calf generates force with each step that we take.  In optimal biomechanics, that force is distributed to the foot in a way that lifts the body and enables forward motion.  But as we age, we start to loose tissue elasticity.  We still have the strength to perform the activities that we want to, but we lack the elasticity to heal.  And that’s what’s at the heart of what causes plantar fasciitis.  Essentially, the strength of the calf overwhelms the ability of the fascia to heal.

And what about the humble heel lift?  A heel lift is used to treat plantar fasciitis in a somewhat indirect manner.  By elevating the heel, you’re weakening the force generated by the calf.  Decreasing the force delivered by the calf to the foot decreases the load applied to the fascia and enables the ability of the fascia to heal.  It’s pretty simple really, raise the heel and the plantar fasciitis will get better.  Lower the heel (barefoot, low heeled shoes) and the plantar fasciitis gets worse.

So I ask you, if you had plantar fasciitis and were looking for cost effective treatment which would you choose; an Rx orthotic at $250(+)/pair or a heel lift at $3.95/pair.  And that’s the point in our conversation that my patient said to me, “man, am I glad I stopped to see you first.”

Treatment of plantar fasciitis doesn’t have to be complicated.  And it’s important to recognize that not all patients will be pain free with the use of a heel lift.  But in my experience, 7/10 are at least 50% improved within 3 weeks.  Not a bad success rate for the humble little heel lift.

Jeffrey A. Oster, DPM
Medical Director
Myfootshop.com

What’s so important about heel lifts? (part 1 of 3: biomechanics)

Let’s talk a little bit about lower extremity biomechanics and how a heel lift can alter normal biomechanical properties.

The calf, ankle and foot are a lever.  The primary function of this lever is to enable walking.  To do so, the calf contracts and delivers a force to the ball-of -the-foot.  The action created by that force is to lift the heel just a bit, but more importantly, this force causes us to begin a forward fall.  That forward fall is due to our center of gravitiy being pushed forward.  As we begin this fall, we react by placing our other foot out to stop the fall.  But to continue walking, the second foot will perform the same task; calf contracts, raises the body just a bit and we continue forward in our forward fall.  That’s what we call walking.  Granted, there’s a lot more to the biomechanics, but what’s at the heart of walking is how the leg, ankle and foot act as a lever to lift us and move us forward.

So what’s a lever?  Levers have three parts.  Force is created by what’s called the effort arm.  Force is received by the opposite end of the lever called the resistance arm.  And in the center is a hinge that enable this transfer of force called the fulcrum.  There’s a number of common examples of levers in life that we use every day such as a nut cracker, pry bar or a teeter totter.  The way that the lever works is that force is generated at one end and received at another.  Still hanging with me?

So in the leg, ankle and foot, we have the calf acting as the effort arm, the ankle acting as the fulcrum and the foot acting as the resistance arm.  With each step, force is delivered from the calf to the foot. 

So what does a heel lift have to do with lever function of the leg, ankle and foot?  The humble little heel lift actually performs a big function.  Raising the heel will weaken the calf.  By weakening the calf, there will be a decrease in the amount of force carried down through the lever with each step.  A small heel lift (3/8 to 12″) can have a significant impact on the amount of force delivered through the lever we call the leg, calf and foot.  But more importantly, think of the sum total of force carried through this lever over the course of a day.  If you change each step so that there’s less force, think of the impact of that change at the end of the day….it’s significant.

Interested in more information on this topic?  Visit our pages on the CT band for a more complete summary of lower leg lever function.

Jeffrey A. Oster, DPM
Medical Director
Myfootshop.com

What’s a turf toe plate and how does it help the symptoms of turf toe?

Turf toe is the term used in athletic circles to describe a condition called hallux limitus.  Hallux limitus is a an injury to the great toe joint that results in pain with range of motion of the joint.  In many cases, arthritis and continued pain are common.  One of the tools used to treat turf toe  is a turf toe plate.

Turf toe plates are a funny looking type of insert.  Most are made out of rigid yet thin material such as carbon and graphite.  The carbon/graphite composite yields a very thin and durable material for athletic use.  But the most unique aspect of the turf toe plate is something called a Morton’s extension.  The Morton’s extension is an extension under the great toe that limits motion of the great toe joint.

The benefit of a turf toe plate is simple.  The rigidity of the turf toe plate and the Morton’s extension limit range of motion of the great toe joint.  A turf toe plate may not correct turf toe.  Only surgery can do that.  But use of a turf toe plate can significantly decrease the pain associated with turf toe.

Jeffrey A. Oster, DPM
Medical Director
Myfootshop.com

The fixation pin used in my foot surgery broke. What do I do?

There’s a number of different ways that bone can be fixated when performing foot and ankle surgery.  We use straight pins called K-wires, screws, plates, absorbable pins and a host of other devices.  In the majority of cases, these pins are placed on a temporary basis to hold the bone stable so that it can heal.  After healing is completed, the fixation device really has no additional benefit, and if possible, should be removed.

In some cases these fixation devices break prior to removal.  Screws can crack in half, pins can break.  The image above shows a partial K-wire that was placed during a hammer toe procedure.  The pin exited the tip of the second to and was anchored into the second metatarsal.  Prior to removing the pin I noticed that the toe was moving more than expected.  Once the pin  was removed, I noticed that the typical sharp tip of the k-wire was not there.  Instead I found a broken end.  X-rays were taken that showed the image above.

So, what should we do about the remaining piece of pin?  In this particular case, the pin is well buried in the head of the second metatarsal.  It’s likely that this remaining piece of pin will never be a problem.  We’re hoping that the pin will remain buried in the bone.  And if that is the case, the best solution would be to leave it alone.  Another, less than optimistic scenario would be that the pin backed out and became lodged in the joint space.  In that case, the patient would notice immediate and significant pain.  Subsequently, the pin would need to be surgically removed.

It’s important to recognize that a metal pin or screw is non-reactive and typically will never be noticed by the patient.  A less-than-honest doc might just not say anything about the remaining fragment of pin.  I think most docs would say that you really do need to have the discussion with your patient to be sure they understand what happened, what may happen in the future and what steps would be necessary to fix the problem.

In this particular case, we did just that.  The patient realizes that it’s OK to leave the pin in place but that we may need to take it out at some point in the future.

Jeffrey A. Oster, DPM
Medical Director
Myfootshop.com

Insertional Achilles tendonitis – treatment options

Achilles tendonitis can be broken into three distinct types. 

1. Body of the tendon – This form of tendonitis usually is a manifestation of a small micro tear of the tendon proximal to the insertion into the back of the heel.  Fusiform swelling of the tendon surrounds the area of the tear (fusiform meaning a tubular swelling that encompasses the entire tendon). 
2. Insertional tendonitis – Insertional Achilles tendonitis describes a form of tendonitis specific to the insertion of the tendon into the posterior heel (calcaneus). 
3. Combined body/insertional Achilles tendonitis – This form represents both type 1&2 above.

Let’s focus this conversation on type 2 or what’s called insertional Achilles tendonitis. 

Etiology – How and why do some folks develop insertional Achilles tendonitis?  In a limited number of cases we’ll be able to relate a direct injury to the onset of the pain.  But the majority of patients will relate no specific injury.  Instead, a slow and gradual onset of pain is described.  Pain may be associated with an increase in activity.  Activity examples include that walk for the cure last Saturday or a new exercise program.  For most patients, the primary reason for insertional Achilles tendonitis will be chronic tugging of the Achilles tendon on the posterior heel that cannot heal within a 24 hour period of time.  Therefore, we could classify insertional Achilles tendonitis as a form of overuse syndrome.

Symptoms – Symptoms of insertional Achilles tendonitis include pain with the onset of activity.  Examples of activities would include posterior heel pain when rising from bed or after a period of sitting.  As the symptoms of insertional Achilles tendonitis increase over time, pain will be present for a longer period of time throughout the day.  Hypertrophy (enlargement) of the posterior heel is common.  Hypertrophy of the posterior heel is a response to traction (pulling) on the bone.  The heel bone responds by calcifying the insertion of the Achilles resulting in a pronounced enlargement of the posterior heel.

Treatment – Unfortunately, treatment options for insertional Achilles tendonitis can be limited.  Conservative care includes the use of a heel lift, calf stretches and anti-inflammatory medications.  I’ve not found physical therapy or cast immobilization to be effective in cases of insertional Achilles tendonitis.  Most case that do not respond to a heel lift and calf stretches will benefit from surgical correction of the problem.  Surgical correction is performed on an out-patient basis and involves partial resection of the heel bone or what we previously called the hypertrophic heel.  A partial lengthening of the Achilles tendon is often used.

The frustrating aspect of care for both patient and provider is the limited number of treatment options available.  Either the conservative care works or we’re off to surgery.  And that’s a tough set of choice knowing that surgical care is going to require 8 weeks in a hard, non-weight bearing cast.  Surgery is successful, but the disability is quite a hit on the chin for patients.

Jeffrey A. Oster, DPM
Medical Director
Myfootshop.com

I wore a neck tie to work…never again.

Early in may career, my work attire consisted of a white lab coat and neck

The fomite neck tie

 tie.  It was the uniform of the times and was how patients expected to see their doctor.  Over time, I became more casual and got out of the habit of wearing a tie.  But yesterday was a special event and for once in a blue moon, I wore a tie.  By the end of the day I had realized what an effect carrier of bacteria I wore around my neck.

A carrier of bacteria?  Let me explain.  Throughout the day I made ongoing, casual observations of my humble neck tie and how many times it was dragged through an infectious environment.  I saw a patient with an infected ulcer…neck tie was tucked in my shirt against my own skin.  Another patient had advanced arterial disease with gangrene…neck tie drug on the floor as I tried to maneuver to see this patient who was wheel chair bound.  And going to the bathroom, the tie hit the edge of the toilet as I went to raise the lid on the toilet.

And the end of the day?  I wore my tie to a hospital staff dinner.  As I sat there, all I could do is think of all of the ties in the room that had been drug through the infection zones of podiatry, ENT, internal medicine…you name it.  Moral of the story is that we really need to re-think our infection control policies.  Sometimes the simplest changes in our approach to infection can have the greatest impact.

Where can you start to improve nosocomial transmission of infection?  Don’t be a fomite.  Wash your hands…and ditch the neck tie.

Jeffrey Oster, DPM
Medical Director
Myfootshop.com

Hands on care – the lost art of medicine.

Hands on care.  Touch, as part of the medical exam, used to be a significant and meaningful part of the exam.  Touch was not only a means by which we would arrive at a diagnosis, but touch was also used to reassure and calm an anxious patient.  But interestingly, we’re starting to rely on touch less and less in this new, high tech health care delivery model.  Why?  I think it boils down to the competition between documentation and touch.  Basically, documenting the visit is taking precedence over what we once knew as the art of medicine.

I trained in an osteopathic hospital.  For one week of my residency, I rotated with a DO who’s entire practice was manipulation therapy.  And you know, I learned a lot.  One of the things I learned was that each part of the body has a natural rhythm.  When pain is present (post injury, secondary to disease), that natural rhythm is lost as reflexive splinting occurs.  As an example, think of a pinched nerve in your neck.  The natural response by your body is to use reflexive muscle splinting to limit the range of motion that can pinch the nerve even more.  In essence, the body locks down the neck in response to the pain.  One of the most important methods of easing that splinting is manipulation.  Not abrupt cracking of the joints, but subtle range of motion to weaken the splinting and restore normal range of motion.  Physical therapy would often be called upon to accomplish this task.

Now, let’s introduce  the lap top computer into the scenario described above.  Would there be hands on care?  Evaluation of range of motion?  Muscle strength testing?  Maybe.  We’ve used electronic medical records for 6 years and often describe the presence of a lap top as the third person in the room.  Not only is the computer a distraction, but it contribute to decreased physical contact with the patient.  In my practice as a podiatrist, I touch a lot of infected patients.  That contact and subsequent contact with my lap top has to be limited.  Forgot to get a pulse?  The gloves go back on again.  Oh, forgot to measure the depth of that ulcer?  Gloves go back on again.  But the alternative is to just not touch the patient.  One way to accomplish that is to have your assistant do all the contact…..because heck, I’m too busy writing the progress note.

My solution has been to leave my computer in my office.  Sure, it’s less efficient.  But I go see two or three patient’s, look them in the eye, touch them and then go back to my office to complete the note.  And I stop to wash my hands on the way to the computer.  And you know, at the end of the day I’m certain that my patients have understood directions that they need to follow, understand how to take their prescriptions and feel as if the doctor (me) is a better partner.  One who listens, touches and cares.

Jeffrey A. Oster, DPM
Medical Director
Myfootshop.com

How do I treat turf toe?

Turf toe describes an injury to the great toe joint.  Turf toe is the athletic term used to describe a condition better known as hallux limitus.  There are four contributing casues for the onset of hallux limitus, but in cases of turf toe, the most common reason for onset is a jamming injury of the great toe joint.  There are also 4 stages of turf toe (hallux limitus).  What I’d like to discuss in this post is how each of the four stages is treated.  Most importantly, to be sure you’re purchasing the correct products for your hallux limitus, be sure to familiarize yourself with the 4 stages of hallux limitus.

Stage 1 turf toe (hallux limitus) describes an injury to the surface cartilage of

radiographic anatomy of the foot

the great toe joint.  One of the simple tricks to ‘off-load’ stage 1 injuries is to use a pad to plantarflex the the bone just behind the great toe called the 1st metatarsal.  The range of motion of the great toe can be significantly improved by plantarflexing the 1st metatarsal.  The best way to accomplish this is with

 

 the use of a dancer’s pad.  Using a dancer’s pad can be a little tricky at first, but once placed in the correct position, the 1st metatarsal will plantarflex and improve the range of motion of the joint.  Better range of motion means less pain.

As we progress into stage 2, the use of a dancer’s pad becomes less useful.  The reason that a dancer’s pad may no longer work is due to the fact that the joint now is starting to undergo physical change.  Classic findings of stage 2 (see link above to hallux limitus) include dorsal beaking of the joint and early chondromalacia (degenerative change of the cartilage).  Early stage 2 may benefit from a dancer’s pad but as we move to late stage 2 and stage 3, dancer’s pads will become ineffective.

In stage 3 we need to change our approach to treatment.  Rather than trying to improve the range of motion of the great toe, we do just the opposite.  We actually limit the range of motion of the joint.  To limit range of motion, we employ two tools; a turf toe plate or a carbon spring plate.  Both devices are thin yet rigid inserts that are used to prevent motion at the toe off phase of gait.

And stage 4?  We can still use a turf toe plate but in most cases we’ll find that joint replacement or joint fusion is going to be the best approach to treatment.

So first things first.  To treat hallux limitus, first be sure to familiarize yourself with the clinical symptoms of each stage of hallux limitus as described in our knowledge base article.  And once you’ve defined your stage, you’ll be much more able to treat your problem with turf toe.

Jeffrey A. Oster, DPM
Medical Director
Myfootshop.com