How does bone edema heal?  The first issue to consider when discussing bone edema is the primary cause for the bone edema.  For instance, if bone edema is secondary to an infection, the infection has to be treated for the bone edema to heal.  Or if the bone edema is due to a stress injury, the mechanical stress needs to be eliminated. 

Once the primary cause for bone edema is identified and eliminated, then we can look at the dynamics of bone healing in response to bone edema.  One classic tool that helps to determine the rate of bone healing is a classification scheme.  In many types of bone injuries/fractures we use classifications schemes to define characteristics of the injury such as depth of the injury, overall size of the injury, etc.  Classification schemes help to guide us with answers to our patient’s question such as how long will this take to heal.  But when we discuss bone edema, we have a problem.  To date, we’ve had a difficult time defining bone edema in a classification scheme.  And without a classification scheme, we then have a difficult time answering that question…how long will this bone edema injury take to heal.

In my practice (foot and ankle care), I’ve tended to find that when we discover bone edema on an MRI, the injury may take as long if not longer than most fractures to heal.  For instance, a common foot problem that we’ll see is a metatarsal stress fracture.  If the stress fracture doesn’t show on plain x-ray, we’ll send our patient for an MRI.  And if that MRI comes back with a diagnosis of bone edema within the metatarsal, we then have an idea about overall time that it’ll take for bone healing.  What’s the typical duration of time for a metatarsal stress fracture?  I’d tell most folks 8-12 weeks.  But with bone edema in the metatarsal, it may take as long if not longer than a traditional fracture.

Additional variables that influence the duration of healing of bone edema include the size of the bone that is injured, the type of bone that is injured, the depth of the injury and the overall size. 

Unfortunately, until we can develop a classification scheme for defining the healing rate of bone edema, each doc just draws from his or her experince with previous patients and similar injuries.  So if your doctor recommends an MRI and your MRI comes back with a diagnosis of bone edema, be patient with your doc.  She/he will try to guide you with answers, but defining how long bone edema will take to heal can be a challenge.

Jeffrey A. Oster, DPM
Medical Director
Myfootshop.com

During the course of taking a history of a patient with suspected OA of the feet, one of the first things that I do is look at the patients hands.  Bumps on the knuckles of the fingers known as Heberden’s nodes are a dead ringer for OA of the feet.  Since we know that most OA is symmetrical, we can bet on the fact that a patient with OA in the fingers is also going to have OA in the feet.

OA of the feet is caused by either an early injury to the feet or due to a predisposition to OA.  An injury to the foot can be any number of different problems.  I’ve seen a a patient in her mid forties over the past several months who sustained an injury to her arch in a high school basketball game.  The injury, known as a Lisfranc’s dislocation was undiagnosed for all these years.  Over time, the untreated injury slowly progressed to a stage where the patient was unable to bear weight on the arch.

Another more common form of injury is repetitive use.  Structural deformities of the foot can place excessive and unbalanced (eccentric) load on the arch.  These structural deformities include a high arch foot, flat foot or metatarsus adductus.  With each step, this imbalance will apply excessive load to the foot resulting in an injury.  Over time, this will predispose a patient to OA.

How do you treat OA of the midfoot?  Methods used to treat OA are pretty much the same regardless of the location in the body.  Those methods include bracing, use of an anti-inflammatory or surgery.  As a foot surgeon, I’ll be the first to tell you that surgery on the midfoot for OA is difficult to say the least.  Success rates are not the best.  If we compare surgery on midfoot arthritis to say a knee replacement or hip replacement for OA, I can say with certainty that we have a long way to go to get better at our art.

Anti-inflammatories?  Anti-inflammatory medications can have mixed results when treating OA.  Some folks will respond to simple OTC medications like Glucosamine while others have difficult even with the most potent of Rx medication.  I think you have to keep in mind though that the further along the OA, the less effective the anti-inflammatory medication.

Now let’s get to the heart of what I really wanted to talk about, and that’s bracing.  Whoever invented the Oxford shoe was a genius.  Sure, it isn’t pretty, but when it was first invented, the Oxford shoe was used as a brace.  Over time we’ve incorporated it as a fashion statement.  Paint it white and put a little swoosh on the side and you’ve got a running shoe which is really an Oxford in disguise.

The attributes of an Oxford, when used as a brace, are three fold; stiff shank, tied upper and a little heel.  This combination of attributes not only protects the foot but also creates a brace that can support problems such as OA.  A little heel will weaken the calf to decrease force that is applied to the OA with each step.  And the stiff shank enables force from the calf to be carried where it is most effective at the ball of the foot.  And the ties?  The ability to tie the shoe simply lashes the foot to the stiff shank.  Honest, the folks that invented the Oxford really had it all figured out.

We’ll often tweak a shoe to work better when treating OA.  For instance, if you have a tennis shoe that has a soft shank, we’ll but a still carbon graphite spring plate into the shoe.  In that way you can still use your existing shoes and not have to buy new shoes. 

Treating OA can be rewarding is you just stick to the basics of care.  Bracing is so important in treating this condition.  But as mentioned above, bracing can be quite simple.  Many of us will already have the solution lying in the bottom of our clothes closets.

Jeffrey A. Oster, DPM
Medical Director
Myfootshop.com

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

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

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

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

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

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

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

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