Morton's Neuroma

Morton's Neuroma

If you sometimes feel that you are "walking on a marble," and you have persistent pain in the ball of your foot, you may have a condition called Morton's neuroma. A neuroma is a benign tumor of a nerve. Morton's neuroma is not actually a tumor, but a thickening of the tissue that surrounds the digital nerve leading to the toes.

Morton's Neuroma shown in circled area.

Definition

Morton's neuroma occurs as the nerve passes under the ligament connecting the toe bones (metatarsals) in the forefoot.

Morton's neuroma most frequently develops between the third and fourth toes, usually in response to irritation, trauma or excessive pressure.

The incidence of Morton's neuroma is 8 to 10 times greater in women than in men.

Symptoms

• Normally, there are no outward signs, such as a lump, because this is not really a tumor.
• Burning pain in the ball of the foot that may radiate into the toes. The pain generally intensifies with activity or wearing shoes. Night pain is rare.
• There may also be numbness in the toes, or an unpleasant feeling in the toes.

Runners may feel pain as they push off from the starting block. High-heeled shoes, which put the foot in a similar position to the push-off, can also aggravate the condition. Tight, narrow shoes also aggravate this condition by compressing the toe bones and pinching the nerve.

Diagnosis

During the examination, your physician will feel for a palpable mass or a "click" between the bones. He or she will put pressure on the spaces between the toe bones to try to replicate the pain and look for calluses or evidence of stress fractures in the bones that might be the cause of the pain. Range of motion tests will rule out arthritis or joint inflammations. X-rays may be required to rule out a stress fracture or arthritis of the joints that join the toes to the foot.

Treatment

Initial therapies are nonsurgical and relatively simple. They can involve one or more of the following treatments:

• Changes in footwear. Avoid high heels or tight shoes, and wear wider shoes with lower heels and a soft sole. This enables the bones to spread out and may reduce pressure on the nerve, giving it time to heal.
• Orthoses. Custom shoe inserts and pads also help relieve irritation by lifting and separating the bones, reducing the pressure on the nerve.
• Injection. One or more injections of a corticosteroid medication can reduce the swelling and inflammation of the nerve, bringing some relief.

Several studies have shown that a combination of roomier, more comfortable shoes, nonsteroidal anti-inflammatory medication, custom foot orthoses and cortisone injections provide relief in over 80 percent of people with Morton's Neuroma. If conservative treatment does not relieve your symptoms, your Podiatric surgeon, Dr. Raymond A. DiPretoro, Jr. may discuss surgical treatment options with you. Surgery can resect a small portion of the nerve or release the tissue around the nerve, and generally involves a short recovery period.

Skin Cancer...Be Sure To Check Your Feet Too!

 Malignant melanoma is one of the most common forms of skin cancer, with one in five Americans diagnosed at some point in their lifetime. This statistic is largely due to the damaging effect of the sun. During our hot and humid summers, it is common to wear open shoes, which puts our feet at significant risk of developing melanoma.

Too often melanoma is assumed to be something else....like a plantar wart, callus, or just a birthmark. This leads to a delay in identifying and treating the cancer. When it comes to melanoma, early detection is the key!

If a lesion is suspicious, identification is a simple process. A small injection to numb the area, followed by a shave or punch of the lesion will give us all the information we need to ensure you do not have cancer. Thre is no down time, no stitches, and the whole procedure takes about five minutes.

In a matter of days, we will have the results and be able to treat it if necessary. The first step is for you to get it checked! If you have noticed a spot on your foot or ankle that has been changing in size or color, contact Newark Podiatrist, Dr. Raymond A. DiPretoro, Jr.. We'll be able to see if it is something to be concerned about and give you the piece of mind that you need.

In the mean time...don't forget to use sunscreen!! And don't forget your feet!

Stress Fractures of the Foot and Ankle.

Stress Fractures of the Foot and Ankle

A stress fracture is a small crack in a bone. Stress fractures often develop from overuse, such as from high-impact sports like distance running or basketball.

Most stress fractures occur in the weight-bearing bones of the foot and lower leg. Studies show that athletes participating in tennis, track and field, gymnastics, dance, and basketball are at high risk for stress fractures. In all of these sports, the repeated stress of the foot striking the ground can cause problems.

Rest is the key element to recovery from a stress fracture.

Description

A stress fracture is an overuse injury. When muscles are overtired, they are no longer able to lessen the shock of repeated impacts. When this happens, the muscles transfer the stress to the bones. This can create small cracks or fractures.

The most common sites of stress fractures are the second and third metatarsals of the foot. Stress fractures are also common in the heel (calcaneus), the outer bone of the lower leg (fibula), and the navicular, a bone on the top of the midfoot.

The most common sites for stress fractures in the foot are the metatarsal bones.

Cause

Stress fractures usually occur when you increase your high-impact activity by:

• Frequency (how often you exercise)
• Duration (how long you exercise)
• Intensity (your level of exertion)

People who do not exercise can also have stress fractures. If osteoporosis or other disease has weakened bones, normal daily activities may result in a stress fracture. This is called bone insufficiency. It is one of many factors that can increase your risk for stress fracture.

Conditioning

Doing too much too soon is a common cause of stress fractures. For example, runners who are confined indoors for the winter may want to pick up where they left off at the end of the previous season. Instead of starting slowly, they try to match their previous mileage. Because of the lower level of conditioning, muscles become fatigued faster. The result could be a stress fracture in the foot or ankle.

Those who are new to exercise and try to do too much too soon are also at risk.

Equipment and Environment

Improper sports equipment, such as shoes that are too worn or stiff, can contribute to stress fractures.

A change of surface, such as going from a grass tennis court to one of clay, or a change from an indoor to an outdoor running track, can also increase the risk.

Technique

Errors in training or technique are another cause of stress fractures. Anything that alters the mechanics of how the foot absorbs impact when it strikes the ground may increase your risk for a stress fracture. For example, a blister, bunion, or tendonitis can affect how you put your weight on your foot, and may require a bony area to handle more load than usual.

Bone Insufficiency

Insufficiency stress fractures result when the bone itself is weak. Conditions like osteoporosis reduce bone strength and density. This increases the risk of fracture.

Anyone with a medical problem or taking medication that decreases bone density is susceptible to stress fractures.
Female athletes who experience irregular or absent menstrual periods may also have decreased bone density. Studies show that female athletes are more prone to stress fractures than their male counterparts are. Many doctors attribute this to "female athletic triad." This three-sided condition includes eating disorders, irregular menstrual cycle, and osteoporosis. As a woman's bone mass decreases, her chances for getting a stress fracture increase.

Symptoms

• Pain that develops gradually, increases with weight-bearing activity, and diminishes with rest
• Pain that becomes more severe and occurs during normal, daily activities
• Swelling on the top of the foot or the outside of the ankle
• Tenderness to touch at the site of the fracture
• Possible bruising

Doctor Examination

Medical History and Physical Examination

During the first visit, your doctor will ask you about your work, your activities, and any medications you take. It is important that your doctor understands what your risk factors for stress fractures are.

After discussing your symptoms and medical history, your doctor will examine your foot and ankle.

Imaging Tests

Imaging tests may help your doctor confirm your diagnosis.

Stress fractures are difficult to see on X-rays until they have actually started to heal. Your doctor may recommend a bone scan or a magnetic resonance imaging (MRI) scan, which are more sensitive than an X-ray and can detect stress fractures early.

Treatment

First Aid

If you suspect a stress fracture in your foot or ankle, stop the activity and rest. Ignoring the pain can have serious consequences. The bone may break completely.

Apply an ice pack and elevate your foot above the level of your heart. Nonsteroidal anti-inflammatory medicines like ibuprofen or naproxen may help relieve pain and swelling, but may inhibit bone healing. Try not to put weight on your foot until after you see a doctor.

Nonsurgical Treatment

Treatment will vary depending on the location of your stress fracture and its severity.

The goal of any treatment is to help you return to all the activities you enjoy. Following your doctor's treatment plan will restore your abilities faster, and help you prevent further problems in the future.
Rest. Take a break from the activity that caused the stress fracture. It typically takes 6 to 8 weeks for a stress fracture to heal. During that time, switch to aerobic activities that place less stress on your foot and leg. Swimming and cycling are good alternative activities. Remember, however, that you should not do any physical activity on the involved foot or ankle until you consult a doctor.
Protective footwear. To reduce stress on your foot and leg, your doctor may recommend wearing protective footwear. This may be a stiff-soled shoe, a wooden-soled sandal, or a removable short-leg fracture brace shoe.
Casts. Stress fractures in the fifth metatarsal bone (on the outer side of the foot) or in the navicular or talus bones take longer to heal. Your doctor may apply a cast to your foot to keep your bones in a fixed position and to remove the stress on your involved leg. Casts are a type of external fixation. To keep weight off your foot and leg, your doctor may recommend that you use crutches until the bone heals.

Surgical Treatment

Some stress fractures require surgery to heal properly. In most cases, this involves supporting the bones by inserting a type of fastener. This is called internal fixation. Pins, screws, and/or plates are most often used to hold the small bones of the foot and ankle together during the healing process.

Recovery

Once your stress fracture has healed and you are pain-free, your doctor will allow a gradual return to activity.

Slow pace. During the early phase of rehabilitation, your doctor may recommend to alternate days of activity with days of rest. You should slowly increase the frequency, duration, and intensity of your exercise. If the activity that caused the stress fracture is resumed too quickly, larger, harder-to-heal stress fractures can develop. Reinjury could lead to chronic problems, and the stress fracture might never heal properly.

Cross-training. Varying the types of aerobic exercise you do may help you avoid repeated stress on your foot and ankle.

Prevention

These guidelines can help you prevent stress fractures.

• Maintain a healthful diet. Eat calcium and Vitamin D-rich foods to help build bone strength.
• Use proper sports equipment. Don't wear old or worn running shoes.
• Alternate your activities. For example, you can alternate jogging with swimming or cycling.
• Start any new sports activity slowly. Gradually increase time, speed, and distance; a 10% increase per week is fine.
• Strength training can help prevent early muscle fatigue and prevent the loss of bone density that comes with aging.
• If pain or swelling returns, stop the activity. Rest for a few days. If pain continues, see your Podiatrist, Dr. Raymond A. DiPretoro, Jr. at Advanced Foot and Ankle Center!.

Do you have Arch Pain?

Definition 

The term arch pain (often referred to as arch strain) refers to an inflammation and/or burning sensation at the arch of the foot.

Cause

There are many different factors that can cause arch pain. A structural imbalance or an injury to the foot can often be the direct cause. However, most frequently the cause is a common condition called plantar fasciitis. The plantar fascia is a broad band of fibrous tissue located along the bottom surface of the foot that runs from the heel to the forefoot. Excessive stretching of the plantar fascia, usually due to over-pronation (flat feet), causes plantar fasciitis. The inflammation caused by the plantar fascia being stretched away from the heel often leads to pain in the heel and arch areas. The pain is often extreme in the morning when an individual first gets out of bed or after a prolonged period of rest. If this condition is left untreated and strain on the longitudinal arch continues, a bony protrusion may develop, known as a heel spur. It is important to treat the condition promptly before it worsens.

Treatment and Prevention

This is a common foot condition that can be easily treated. If you suffer from arch pain avoid high-heeled shoes whenever possible. Try to choose footwear with a reasonable heel, soft leather uppers, shock absorbing soles and removable foot insoles. When the arch pain is pronation related (flat feet), an orthotic designed with a medial heel post and proper arch support is recommended for treating the pain. This type of orthotic will control over-pronation, support the arch and provide the necessary relief.

If the problem persists, consult Dr. Raymond A. DiPretoro, Jr.'s office!

Foot and Ankle Osteoarthritis

Foot and Ankle Osteoarthritis

As you age, your chance of developing osteoarthritis, which is caused by wear and tear, increases. The joint damage associated with osteoarthritis causes swelling, pain, and deformity. Here is information about how osteoarthritis affects the foot and ankle and information you can use to help you manage this debilitating condition.

What Is Arthritis?

Arthritis is a general term for a group of more than 100 diseases. The word "arthritis" means "joint inflammation." Arthritis involves inflammation and swelling in and around the body's joints and surrounding soft tissue. The inflammation can cause pain and stiffness.

In many kinds of arthritis, progressive joint deterioration occurs and the smooth "cushioning" cartilage in joints is gradually lost. As a result, the bones rub and wear against each other. Soft tissues in the joints also may begin to wear down. Arthritis can be painful and eventually result in limited motion, loss of joint function, and deformities in the joints affected.

What Is Osteoarthritis?

Osteoarthritis, or "wear-and-tear" arthritis, is the most common type of arthritis. Also known as degenerative joint disease or age-related arthritis, osteoarthritis is more likely to develop as people age. Inflammation and injury to the joint cause a breaking down of cartilage tissues, resulting in pain, swelling, and deformity. The changes in osteoarthritis usually occur slowly over many years, though there are occasional exceptions.

How Does Osteoarthritis Affect the Foot and Ankle?

Each foot has 28 bones and more than 30 joints. The following are the most common foot joints affected by osteoarthritis:

• The joint where the ankle and shinbone meet
• The three joints of the foot that involve the heel bone, the inner mid-foot bone, and the outer mid-foot bone
• The joint of the big toe and foot bone

What Are the Symptoms of Foot and Ankle Osteoarthritis?

Symptoms of foot and ankle osteoarthritis often include:

• Tenderness or pain
• Reduced ability to move, walk, or bear weight
• Stiffness in the joint
• Swelling in the joint

How Is Foot and Ankle Osteoarthritis Diagnosed?

The diagnosis of foot and ankle osteoarthritis most likely will involve:

• A medical history in which the doctor asks questions about when and where the pain began
• X-rays
• Bone scans
• Magnetic resonance imaging (MRI)

How Is Foot and Ankle Osteoarthritis Treated?

Foot and ankle osteoarthritis can be treated in many ways. Nonsurgical methods to treat foot and ankle arthritis include:

• Steroid medications injected into the joints
• Anti-inflammatory drugs to reduce swelling in the joints
• Pain relievers
• Pads or arch supports
• Canes or braces to support the joints
• Inserts that support the ankle and foot
• Physical therapy
• Custom shoes
• Weight control

Tips on Foot Care With Osteoarthritis

The most essential element of foot care for people with foot and ankle osteoarthritis is to wear shoes that fit properly and feel comfortable. The following are things to look for in finding a comfortable shoe:

• Shoes shaped like your foot
• Shoes that have support -- for example, no slip-on shoes
• Rubber soles to provide more cushioning
• Flexibility
• Proper fit -- ask the salesperson to help you with this

Exercise can help keep your feet pain-free, strong, and flexible. Exercises that can be good for your feet include:

• Achilles stretch. With your palms flat on a wall, lean against the wall and place one foot forward and one foot back. Lean forward, leaving your heels on the floor. You can feel the pull in your Achilles tendon and your calf. Repeat this exercise three times, holding for 10 seconds on each repeat.
• Big-toe stretch. Place a thick rubber band around your big toes. Pull the big toes away from each other and toward the other toes. Hold this position for five seconds and repeat the exercise 10 times.
• Toe pull. Place a rubber band around the toes of each foot, and then spread your toes. Hold this position for five seconds and repeat the exercise 10 times.
• Toe curl. Pick up marbles with your toes.
• 
  
• Is Surgery an Option for Foot and Ankle Osteoarthritis?
• More than one kind of surgery may be required to treat foot and ankle osteoarthritis. Your doctor can select the kind of surgery that is best for you, depending on the extent of your arthritis. The following are some of the surgical options for foot and ankle osteoarthritis:

  • Fusion surgery. This kind of surgery, also called arthrodesis, involves fusing bones together with the use of rods, pins, screws, or plates. After healing, the bones remain fused together.
  • Joint replacement surgery. This kind of surgery involves replacing the ankle joint with artificial implants and is used only in rare cases.

Women's Foot Health

Summer is the Time to Leave High Heels in the Closet

The long hot  summer is well under way, and with its arrival, sweaters, long pants and jackets have all been sent to the back of our closets. While you’re switching up your wardrobe for the season, why not give your feet a break too, suggests Newark podiatrist Dr. Raymond DiPretoro. If you alter your high-heel wearing routine over the next few months, you may save yourself from years of foot pain.

Most women joke about the pain they feel after a long day or night wearing their heels, but few realize just how much damage their shoe habit may be causing. Earlier this year, Sarah Jessica Parker, the virtual spokesperson for high heels, revealed that her Manolo-habit had caused her to develop bone spurs and bunions.

Besides these two nasty problems, high heels can also cause: neuromas, characterized by pain in the ball of your foot; plantar fasciitis, which manifests as sharp heel pain; hammertoes, or an unnatural curling of the toes; pump bumps, or a swelling of the bone on the back of the foot; and bunions, which, although genetic, can be made worse by continuous high heel wearing.

If you’re wondering why those heels are so bad for you, just think about the physics of it—when you walk in high heels, up to 80 percent of your body weight has to be supported by the front of the foot. That puts a lot of added pressure on the bones of your feet, causing all the problems discussed above.

Additionally, constantly wearing high heels can make it incredibly uncomfortable to wear any other kind of shoe, because the heels can shorten your calf muscles, causing the Achilles tendon to thicken and stiffen. If you wear heels frequently enough, the calf muscle fibers may permanently shrink, making it too painful for them to stretch out in order to walk on flat feet.

So what’s a high heel lover to do? Give your feet a bit of a break this summer and follow these simple suggestions to avoid permanent foot damage:

• Keep your high heel wearing down to two times a week. If you do have to wear heels daily for work, choose supportive shoes for your commute then change into heels at your desk.
• Choose shoes that have heels lower than two inches.
• Steer clear of stilettos; a wider heel will offer you more support.
• Look for shoes with extra cushioning in the ball of the foot and/or with rubber soles. If you can’t find a shoe that comes with these pads, a simple shoe insert can give you the padding you need.

Hopefully, following these suggestions will keep you walking comfortably in all the shoes in your closet. If, however, you find your high-heel pain does not resolve even after you take off your shoes, schedule an appointment at Advanced Foot & Ankle Center today to improve your quality of life.

Do all bunions need surgery?

A:

Once a bunion forms on your foot, there is no way to correct them other than surgery. The bump on the side of the foot is formed because of a rotation of the bone and bunion surgery repositions the bone to achieve correction. That's not to say that every bunion needs surgery.

In my Advanced Foot & Ankle Center I see the gamut of bunions: from mild-looking bunions that are very painful to horribly deformed bunions that haven't provided a minute of pain. The treatment of a bunion should correlate to the discomfort it provides and its presence restricts you in any way.

Discomfort from a bunion typically comes in two forms: pain deep in the great toe joint and pain where the bunion contacts the shoe. When the pain is in the joint, it is possible to control the function and pressure in that joint by treating it with a custom orthotic. The orthotic will also remove the deforming forces that will cause the bunion to get worse with time. This is a treatment option that many choose to prevent or delay future surgery.

When the pain is related to the bump of the bunion, it makes it difficult to wear shoes comfortably. In some cases, the bunion can be cushioned with a bunion pad. In other cases, foot surgery is the best option to correct the bunion. Bunion surgery will reduce the deformity and will ultimately allow you to return to wearing your shoes comfortably.

Bunions will become worse with time so the best time to get your's checked is now.  Delaware podiatrist and bunion surgeon Dr. Raymond DiPretoro will evaluate your foot and offer the best recommendation to ensure your bunion is addressed in the best way to meet your goals.

Do you have numbness, tingling, or shooting pain to your feet? Do you have foot pain at night?

Why are my feet numb?
Am I diabetic?
Is it a circulation problem?
It seems to be getting worse, is that possible?

These and many other questions are commonly encountered in our office. These symptoms often present in a condition called neuropathy or peripheral neuropathy. 

Neuropathy can be a complex problem with multiple possible causes including diabetes, AIDS or HIV, toxins and metallic poisons, certain chemicals, alcoholism, vitamin deficiencies or nutritional imbalances, it may also occur from systemic diseases (kidney failure, liver disease, rheumatoid arthritis, abnormal blood proteins, cancer especially with chemotherapy, leukemia and shingles). Entrapment may also lead to the symptoms of neuropathy. One key to understanding and treating your neuropathy is to understand the cause. 

Neuropathy symptoms can present as either pain related symptoms or loss of function.  Of these the most common symptoms often present in several ways or even a combination of these:

• Numbness or Tingling
• Electric Shocks
• Shooting Pain
• Stabbing Pain
• Burning Pain

To better illustrate how these symptoms are a continuum from normal sensation to absence of sensation, the following graph is utilized.  Although this is not completely accurate due to varying nerve involvement and individual interpretation of pain and discomfort, it allows individuals to graph their current pain location and understand the daily variance (or the increased pain with some treatments as the neuropathy improves).

Through proper evaluation, treatments can be initiated to alleviate symptoms and possibly even improve neuropathy. Neuropathy options are progressing rapidly and will continue to progress over the next several years. If someone tells you that nothing can be done, they are not staying abreast of current treatment options. Pain is never normal whether caused by neuropathy or some other cause.

When Do I Need New Orthotics?

When Do I Need New Orthotics?

Contrary to popular opinion, custom foot orthotics do not last forever! It is amazing to me how many runners come in with an injury and take orthotics out of their shoes that were made when I was in high school! If your orthotics are more than 5 years old, they probably need to be replaced. Feet change and the devices start to wear out.

If you can't remember how old your orthotics are, here are some tips on how to determine if it is time to replace them:

• Your feet hurt!!! That pain you had reduced or cured with the device has made a comeback – I can’t think of a better reason to get your feet and devices checked
•  Yourorthotics are held together with duct tape, gorilla glue and cardboard – those home modifications just don’t do the trick
• If your orthotics wobble, you may fall down – motion in devices that wasn’t there before can lead to foot pain and instability
• The top cover looks is thinner than you remember or has comletely fallen off – with time all materials will flatten and wear, if your top cover is paper thin, looks like a piece of foam Swiss cheese, or has been missing for months, get it replaced.
• Cracks do not give character – cracks in the shell of device can occur with prolonged use, glue is not the answer and neither is duct tape.
•  Added modifications are lost, loose or not providing the control or pressure relief they used too – just like top covers, modifications can flatten with time, and they can loosen and get lost.

These are just a few subtle reminders of when you need to have your orthotics replaced.   Obviously other problems occur.  While most devices last for several years, most insurance companies will replace a device yearly if problems with device are noted, so don’t hesitate and stop by for an evaluation. Just like eye glasses, your orthotics should be evaluated at least once a year by your favorite podiatrist!

Wouldn't a new pair of orthotics feel wonderful?