What bunion products really work?

Patients that present to my office with bunion pain tend to present with two uniquely different kinds of pain.  The first type of pain is no more complex than the simple square peg-round hole phenomenon.  The foot, with the prominent bunion becomes the square peg that can no longer fit into the shoe, or round hole.  The second kind of bunion pain is a bit more common and is what really brings most folks to the office.  This second type of pain is a dull achy sensation in the joint that is the result of the joint functioning in an altered or deviated position.  This pain is deep in the joint and tends to last long after the shoe is removed.  So when we speak of bunion pain, let’s try to address each of these types of pain as two unique types of pain. 

When we speak of conservative care for the first type of pain (square peg/round hole) we can use bunion padding or we can make the round hole larger (shoe modifications).  Myfootshop.com carries a number of pads used to treat this particular bunion pain.  They include a gel bunion pad, foam bunion pad or even a cut-out felt bunion pad.  All are used to protect the foot from the direct pressure applied to the foot from the shoe.  And remember, it’s important to spot stretch the shoe whenever possible.

And the second type of pain?  The arthritic type of pain?  When treating this second type of pain, I will suggest bunion pads that are used to straighten the toe.  Now bear in mind, straightening the toe is not intended to correct the bunion.  The toe is merely straightened to relieve pain.  The deviation of the great toe found in a bunion deformity will never be corrected with anything short of surgery.  But when using a pad to treat this second type of pain, we use two categories of pads; ambulatory pads/splints and splints used at night.  Ambulatory pads can be a foam wedge placed between the toes, gel pads or splints.  My favorite is typically a firm gel toe straightener.  It’s inexpensive and easy to use.  The classic nighttime splint is something called a bunion regulator.  But remember, bunion regulators are a non-ambulatory splint.  We’d recommend this splint most often as a post-op splint to maximize correction of the surgery.

But do these pads really works?  Yes and no.  Yes, the pads can help with day to day pain.  But no, they’re not going to correct the bunion.  What’s most important is knowing what causes the pain you have with your bunion and how it’s best treated with each of these padding choices.

Jeffrey A. Oster, DPM
Medical Director
Myfootshop.com

Why do I have cracked heels?

The callus that forms around the outer margin of the heel is a unique form of callus.  Let’s take a look at how heel fissures and heel callus forms.

Heel fissures before and after debridement.

I think most of us would tend to think of a callus as an area of friction where the skin thickens to protect the body from physical wear and tear.  And that would be correct in most cases.  Although callus is always a response to irritation of the skin, callus doesn’t necessarily form as the result of direct pressure to the skin.  And heel fissures are a wonderful example of these ‘alternative ways’ in which callus can form.

To describe the way heel fissures form, let’s use a silly example.  Take a balloon to the kitchen sink and fill it full of water.  Tie the top of the balloon and set it on the kitchen counter.  As the weight of the water begins to rest on the counter, the shape of the balloon will change.  The balloon will change from a tear drop shape to a hockey puck shape.  During the course of this change, the outer edges of the balloon will begin to be put under tension. 

Getting back to our topic of heel fissures….with each step that we take, the rim of the heel is put under tension just like the edge of the water balloon.  At heel strike, body weight hits the the heel causing expansion of the heel just like the water balloon.  This expansion of the heel results in tension on the outer most margins of the heel.  This tension on the skin is the irritant to the skin that initiates the formation of callus.  So to understand this unique callus, it’s as simple as understanding that heel fissures are not from shoe wear but are instead due to repetitive tension applied to the skin at heel strike.

So what’s the silver bullet to solve chronic heel fissures?  Sorry.  There really isn’t one.  But a little bit of ongoing maintenance can go a long way.  (did you catch the words – on going?)  Softening the heel with callus creams will help to make the skin more pliable and able to sustain the tension applied to the skin at heel strike.  Callus build-up should be removed with a callus file or safety shaver.  And specially designed gel heel pads used for softening heel fissures can be used at night while sleeping.

Heel fissures can become a severe problem in the dry months of winter.  I tend to see severe heel fissures in bigger folks of dark skin (Italian, Greek, African, etc) during the winter months.  Fissure will split and often become infected.  So an ounce of prevention can go a long way.

Jeffrey A. Oster, DPM
Medical Director
Myfootshop.com

Yoga for the feet?

My primary task as a podiatrist is to define pathology and find the most appropriate treatment to address that foot or ankle pathology.  Maybe it’s that I’m a guy in my mid-fifties, but the more I work with folks to find a treatment plan, the more I find a relationship between the proximal body and foot/ankle pathology.  For instance, if we look at the foot as the foundation or basement of the body, how does the function of the foot and lower extremity effect the health of the upper legs and spine?  In younger folks we find that the body is very forgiving and accommodates much of the lower extremity pathology.  But as we age, I tend to find an increasing relationship between the foot and lumbar spine that is often overlooked.

As we age we fall into a natural cycle of overuse injuries.  Age?  Can we define that population?  Most folks from the age of 40-65 years of age are still as active as they’ve always been.  But what this age range has lost is tissue elasticity.  That progressive decrease in tissue elasticity results in an increase in the potential for injury.  Simply put, the balance between strenght and flexibility has progressively become unbalanced.  Strength is still present but flexibility is diminished.

What’s the outcome of this imbalance?  Often, we’ll see this imbalance effect the lumbar spine.  A common problem of aging is lumbar spine compression.  The foramen (outlet portals for the peripheral nerve roots) become smaller due to progressive lumbar spine compression.  In response to this compression, muscle splinting will occur to stabilize the spine.  Both muscle splinting and spinal compression will result in alterations in gait and referred pain to the foot.

As an example of this type of foot/low back imbalance, let’s take a look at a simple case that I’d see in my office.  Susan, a 56 y/o female presents with a chief complaint of dull,diffuse aching foot pain.  Also described is pain in the right great toe joint consistent with hallux limitus. Susan is 5′2″ and weighs 165 with a BMI of 31.  Clinical and radiographic exam finds stage 2 hallux limitus that does not require surgical correction.  But the lack of normal range of motion of the great toe joint will ultimately alter Susan’s gait.  The alteration of gait effects the lumbar spine resulting increase motion to her pre-existing lumbar disc disease.  The outcome is often something called radiculopathy.  Radiculopathy is the term used to describe a compression of the peripheral nerves that ultimately supply the motor and sensory innervation of the lower leg and foot.

Susan and I discussed the need to use a stiff soled shoe to accommodate her hallux limitus (see above link for treatment of hallux limitus).  We also discussed the need to spend 10 minutes each day in a stretching program.  We discussed using Yoga as a means of developing a stretching program that can be used daily to address her lumbar radiculopathy.  Simply put, Susan’s Yoga program is an attempt to address the loss of flexibility that has developed as the result of her foot problem (hallux limitus).

Yoga is a great way to understand your physical strengths and weaknesses.  And it’s so simple.  All it takes is 10 minutes each morning where you are willing to spend a little time on yourself.  Formal Yoga instruction can help you to better understand the methods and techniques of the masters.  But you don’t need to be a master, eat granola or wear Birkenstocks.  You just need to spend a few minutes on yourself.  And by doing so, you’ll prevent injury, be able to to participate more fully in your chosen activities and often eliminate much of the dull achy pain we see so often in lower extremity care.

Did stretching (Yoga) help Susan?  Yes it did.  And she did seek the help of a formal Yoga program as a beginner to learn positions and propper technique.  Fortunately, Susan has kept up her daily stretching program over the past 6 months that we have seen her as a patient.

You can’t find Yoga in a bottle.  And it’s not as simple as taking a pill.  Yoga does take a bit of work on your part.  But the benefits are almost immediate and grow in time.  And Yoga is not just for those who are aging.  It’s a great treatment tool for athlete’s and even children.  Get out there and give it a try.

Jeffrey Oster, DPM
Medical Director
Myfootshop.com

What’s the difference between plantar fasciitis, a heel spur and heel spur syndrome?

The difference?  None actually.  The terms are synonymous.  Let me explain.

More than 75 years ago, when x-rays were a new tool, a group of patients with plantar heel pain presented to their doctor who took an x-ray of the heel.  In a number of cases, patients with plantar heel pain showed evidence of a spur on the bottom of the heel.  Therefore, the name heel spur seem appropriate. 

But about thirty years ago, we started to look a bit closer at the problem of plantar heel pain and found some troubling questions.  Why do some people with a heel spur on x-ray have no history of heel pain?  And why do some people that have no heel spur seem to have the exact symptoms of heel spur patients?  What we came to realize is that what we once knew as a heel spur is not really a bone problem after all.  It is a soft tissue problem.

Soft tissue you say?  Exactly.  The primary reason for plantar heel pain is not a bone problem but is actually due to the pulling of the plantar fascia on the bottom of the heel.  This tugging and pulling of the plantar fascia causes what we call today, plantar fasciitis.

What once was called a heel spur or heel spur syndrome, is now called plantar fasciitis.  And this transition from old terminology to new terminology is very important in understanding the etiology and treatment of plantar heel pain.  If we think of this condition as a heel spur, our treatment plan ends up going down a dirt road in that the focus is on ways to accommodate the spur; horse shoe pad, soft cushion, etc.  And these methods of care rarely address the primary cause of plantar fasciitis.

So what causes plantar fasciitis?  Ironically it’s due to the calf through a relationship we call CT band syndrome.  Check out those links for a good run down on how we acquire plantar fasciitis and how it’s treated.

Jeffrey Oster, DPM
Medical Director
Myfootshop.com

What’s the role of ankle arthroscopy in foot and ankle surgery?

inflammatory tissue of the ankle as seen with arthroscopic surgery

Patients may not realize it, but small joint arthroscopy, such as ankle and shoulder arthroscopy is a relatively new field of surgery.  In my residency program (1983), I was fortunate to train under some of the pioneers in small joint arthroscopic surgery.  As a result, I’ve been able to use arthroscopic surgery for over twenty five years.  In that time, I’ve had an opportunity to come to understand a few subtleties about arthroscopic surgery that I’d like to share.

Twenty five years ago, MRI was a relatively new science.  Insurers were very reluctant to give authorization for an MRI of the ankle.  So form a diagnostic standpoint, plain x-ray was about all we had.  If an ankle was injured and hurt for more that 8 weeks with normal x-ray findings, diagnostic arthroscopy was indicated.  Arthroscopy was used to diagnosis lacerations in cartilage, synovitis, degenerative arthritis and talar dome lesions/fractures.  As MRI became more commonly used in ankle care, we began to use fewer of the ankle scope procedures.  Obviously, if you can use a non-invasive method like an MRI, why scope, right? 

Interestingly, I’m starting to go back to using ankle arthroscopy a bit more these days.  For instance, I had an interesting case last week.  A 48 y/o male had a history of recurring ankle pain and swelling.  His clinical history and symptoms certainly did seem to be consistent with gout.  But each time we tested him for gout, his tests came back normal.  MRI was used to aid in the diagnosis but also came back inconclusive, noting inflammatory disease of the ankle.  I finally scoped the ankle last week and what do you suppose we found?  Tophaceous gout crystals in the joint….pathoneumonic for gout.

Ankle arthroscopy also has a very useful role as a therapeutic modality.  When scoping, a number of different ‘fix-ups’ can be performed.  For instance, inflamed synovium can be resected.  Defects in cartilage can also be repaired.  And even fractures of the talar dome corrected.

So what’s the role of ankle arthroscopy?  Actually, ankle arthroscopy plays a significant role both as a diagnostic tool and a therapeutic modality.  And most importantly, most patients are able to be active much sooner after small joint arthroscopic surgery.  And my gout patient?  He was walking the day after surgery and stated, “I feel better today than I did even the day before surgery.”

Jeffrey Oster, DPM
Medical Director
Myfootshop.com

I sprained my ankle 6 weeks ago. Why does it still hurt?

ankle anatomy

The more I study the ankle, the more I find it to be a phenomenally complex joint.  And I also see the ankle to be a very vulnerable joint to both short term injury and long term disability.  Let’s take a look at both the short term issues (weeks) associated with ankle injuries and the long term disability.

Most ankle injuries are inversion sprains.  Inversion refers to the position of the sole of one foot facing the sole of the other foot.  So when we speak of an ankle sprain, we’re usually referring to an injury to the lateral ankle due to inversion.  Another way to look at a sprain is to think of the leg staying in a fixed position while the foot (at the ankle) is forced into inversion.

How do we treat the acute ankle sprain?  First, an x-ray is usually in order.

Stress inversion testing for ankle instability

  The x-ray is used to screen for a number of different fracture patterns associated with inversion injuries.  If the x-ray shows no indication of fracture, we proceed with the time tested use of RICE; rest, ice, compression and elevation.  What’s the best method of compression?  I’m not a big fan of stirrup braces that you usually see dispensed from an ER or Urgent Care Center.  My preference is to use an elastic compression device.  Once cleared for fracture and RICE has been explained to the patient, we’ll suggest a follow-up visit in 6 weeks if the ankle is still hurting.

Why would the ankle still hurt at 6 weeks post sprain?  There’s a number of different issue that could be contributing to ongoing pain.  These issues include a bone contusion, ligament injury, tendon injury, cartilage injury, high ankle sprain or soft tissue injury to the joint.  A high ankle sprain is an injury to the ligament that holds the bones of the leg together just above the ankle (called the anterior inferior tibial fibular ligament).  Treatment at 6 weeks post ankle sprain will include follow-up plain x-rays and an MRI.  Plain x-rays are used to re-evaluate the ankle for fracture.  Often we’ll see an area of fracture that is healing that was not seen in the original post-injury films.  MRI is used to determine the extent of soft tissue injury and is invaluable at this stage of treatment.

And what if the MRI picks up an injury?  Treatment will depend upon the nature of the injury and the goals of the patient.  The professional athlete will be treated more aggressively than would be a retiree.  Treatment may be conservative to include casting, continued rest, bracing or physical

Ankle arthroscopy

therapy.  Treatment may also be surgical and address issues such as ligamentous laxity, cartilage damage, tendon damage of bone injury.  Fortunately, most of the surgical methods described can be performed arthroscopically.  Arthroscopic, or small incision surgery enables patients to return to activities much sooner.

And what’s the long term prognosis post ankle sprain?  In most cases good.  Sure, a single instance of injury can be enough to cause severe damage, but in most cases, the problems arise with recurrent sprains.  If left untreated, recurrent sprains will result in early ankle arthritis.  Treatment for recurrent sprains usually requires a stabilization surgery to insure longevity of the ankle joint.

Jeffrey Oster, DPM
Medical Director
Myfootshop.com

Morton’s neuroma – what’s the best way to treat it?

This is always a tough question to answer in the office because there really is no one universal way that is best to treat a Morton’s neuroma.  Let’s talk a bit about conservative vs surgical care.

It’s surprising how many of my patients do respond to some simple conservative care.  The use of a metatarsal pad or an insert with a metatarsal pad works surprisingly well.  The science behind a met pad is that the met pad tends to stabilize the metatarsal heads so that they no longer pinch the interdigital nerve.  Met pads can be a bit of a challenge to place, but once positioned in the right spot, they really do work wonders.

The next step upthe ladder of conservative care is the use of cortisone or injectable alcohol.  Both have their pros and cons and that conversation is covered in the link above to Morton’s neuroma.

The EDIN procedure is one of several procedure used to treat Morton's neuroma.

Surgical care?  That’s also a tough one.  I used to do a lot of the EDIN procedures for neuromas but found that at least half of the cases had a partial to complete recurrence of the neuroma by 1 year out.  I’m leaning more to doing traditional neurectomies now through a plantar incision for those patients who fail conservative care.

Join us for an in-depth discussion at our pages on Morton’s neuroma.

 

Jeffrey A. Oster, DPM
Medical Director
Myfootshop.com

Foot Surgery – how long will it take to heal, Doc?

One of the most important aspects of my job as a podiatrist is to help guide patients through a decision making process regarding their surgical care.  And one of the most important aspects of that decision is how long we can anticipate it will take for the surgery to heal.  This decision will have an impact on return to work, social activities, family care and a host of other issues specific to that particular patient’s life.  First, let’s take a look at preoperative considerations.

The first consideration is the patient’s general health status.  Is this patient able to go through this surgery successfully?  Do they have the capacity to heal?  Considerations such as age and comorbidities need to be reviewed.  Co-morbities are the conditions that may affect healing and include arterial or venous disease, diabetes, obesity, heart disease, etc.  As comorbidities become more numerous and complex, the chances of a good outcome from foot surgery obviously decrease.  The most important tool to judge the impact of these comorbidities is a good history and physical exam.

Next, does the patient have the support team at home to complete the surgery?  Are they a widow living on their own or are the a member of a family with a spouse and adolescent children?  Does the patient have an infant at home who will need care?  In each scenario, advanced planning is necessary to insure a good outcome from foot surgery.

What is the nature of the surgery?  I find it interesting that some foot surgery has significantly more disability than a total hip or knee replacement!  For instance, a total hip or knee replacement will be ambulatory within the first few days of surgery.  A fusion of the foot or ankle will require 8-12 weeks of non-weight bearing.  That’s a long time to be on crutches.  Pre-op counseling is imperative to be sure that patient’s recognize the degree of disability associated with their surgery.

OK, let’s fast forward to the question at hand; how long is it going to take to heal following foot surgery?  As a general rule, soft tissue surgery (cysts, nerve releases) will heal in a 2-4 week period.  Sutures are typically in for a 14 day period.  Many soft tissue procedures are what we call ambulatory meaning that the patient can walk beginning the day of surgery.  Granted, you may not want to walk very far, but at least you’ll be able to bear weight on the foot.

Bone procedures will take longer to heal.  Most bone procedures will require an 8 week period of healing before they become structurally capable of being able to bear load (body weight).  This time period does vary widely based upon the nature of the procedure and surgeon preferences.  Some bone procedures, such as a bunionectomy can be performed in a manner in which load can be applied to the foot immediately post-op.  But other procedures such as a triple arthrodesis will require 10 weeks non-weight bearing.

Part of the impetus for this post was a patient I saw yesterday (picture at left).  This patient is 10 weeks post dorsiflectory osteotomy of the 1st metatarsal and a wedge osteotomy of the heel called a Dwyer procedure, right foot.  In the picture you can see how the patient’s right foot (surgery foot) is red while the left foot is white.  This is an excellent example of what’s called reflux hyperemia.  Reflux hyperemia is the vascular response of the foot to both the surgery and 8 week period of casting.  The take home point here is that even though we speak of healing being 8-12 weeks for a bony procedure, the body is still attempting to understand how to manage this injury we call surgery.  And yes, we really can describe surgery as a controlled injury. 

So how long does it really take to heal?  I tell my patients that the first 75% of healing takes place within the first 2 months post-op.  The remaining 25% of healing takes upwards of a year.  This last 25% is a reorganization period where post-op scar tissue is reorganized and essentially, your body optimizes the surgical injury so that it can ultimately function at 100%.  And the example above (reflux hyperemia) is just one of the many issues your body manages in that later 25% of healing.

If you have an interest in a specific condition and how that condition will heal following surgery, be sure to check out our knowledge base on Myfootshop.com.  The majority of the conditions in the knowledge base describe how they can be treated surgically and describe an estimated time frame for healing.

Jeffrey Oster, DPM
Medial Director
Myfootshop.com

Fibular sesamoidectomy – pros and cons

Sesamoid fracture

I just got out of surgery after performing a fibular sesamoidectomy.  In this particular case, the sesamoid had been fractured some 15 years ago and had progressively become necrotic secondary to avascular necrosis (AVN).  In this patient’s case, he is an active runner and hasn’t been able to run in the past two years due to sesamoid pain.  I thought it might be timely to address the pros and cons of a procedure known as a fibular sesamoidectomy.

The fibular sesamoid is one of two sesamoid bones found on the bottom or plantar aspect of the great toe joint (first metatarsal phalangeal joint).  A good way to describe the two sesamoid bones is to compare them to the knee cap (patella).  Each of the sesamoids are used to facilitate the transfer of force (pulling force called traction) generated by a muscle and tendon.  And this transfer of force is around a corner.  In the case of the knee, the quadriceps muscle and patellar tendon use the patella to change direction at the level of the knee.  The same holds true for the sesamoids.  The extensor hallucis brevis (EHB) tendon originates on the bottom of the heel.  The distal tendons (2) of the EHB inset into the base of the proximal phalanx of the great toe.  As the great toe bends, the sesamoids are used to facilitate the transfer of load beneath the great toe joint.

The two most common injuries of the sesamoids are fractures and AVN.  The literature varies in regards to the success of conservative care for sesamoid fractures.  The literature is consistent in the success rate of treating sesamoid AVN noting that the success rate is poor.

The outcome of sesamoid fractures varies due to a number of contributing factors.  Those factors include the patient’s general health and ability to heal, activities to which the patient wishes to return to, the extent of the fracture and the patient’s age.  Many sesamoid fractures will go on to form a fibrous union that is not truly bone, but is structurally sufficient to support load applied to the fracture site.  And in a small percentage of patient, the fracture results in degenerative change of the dorsal articular surface of the sesamoid.  This degenerative change in the cartilage is called chondromalacia and result in pain with weight bearing.

Excision of the fibular sesamoid is typically a reliable procedure reserved for folks who fail to respond to conservative post fracture.  Once healed, the balance of the three tendons that pull on the plantar aspect of the great toe is weakened subsequent to the excision of the fibular sesamoid.  But in the great majority of cases, the balance is sufficient to maintain a stable great toe joint.

Granted, no one wants to be faced with the decision to have a fibular sesamoidectomy, but out goal with my patient today is to have him non-weight bearing for 3 weeks.  This is customary during the first few weeks of healing with a plantar incision.  Pedestrian activities will follow for 3 weeks and hopefully we’ll see this patient back and running at about 8 weeks post-op.

Jeffrey A. Oster, DPM
Medical Director
Myfootshop.com

Shin Splints – anterior and posterior. Are they the same?

There are two types of shin splints called anterior and posterior.  The most common shin splint is anterior marked in the image to the left in blue.  Anterior shin splints in runners are often due to over striding or training at a pace that doesn’t allow for healing of the tibialis anterior muscle.

Posterior shin splints (also called posterior tibial tendonitis) are a less common condition that is often due to pronation (flattening of the arch).

For more information on shin splints please follow this link to the Myfootshop.com Knowledge Base or join us in the sports medicine thread in The Foot Talk Forum.

Jeffrey Oster, DPM
Medical Director
Myfootshop.com