Swollen Ankles and Feet

Swollen Ankles and Feet

Swollen ankles and swollen feet are common and usually not cause for concern, particularly if you have been standing or walking a lot. But feet and ankles that stay swollen or are accompanied by other symptoms could signal a serious health problem. 

Pregnancy complications. Some swelling of the ankles and feet is normal during pregnancy. Sudden or excessive swelling, however, may be a sign of preeclampsia, a serious condition in which high blood pressure and protein in the urine develop after the 20th week of pregnancy. If you experience severe swelling or swelling accompanied by other symptoms such as abdominal pain, headaches, infrequent urination, nausea and vomiting, or vision changes, call your doctor immediately.

Foot or ankle injury. An injury to the foot or ankle can lead to swelling. The most common is a sprained ankle, which occurs when an injury or misstep causes the ligaments that hold the ankle in place to be stretched beyond their normal range. To reduce the swelling from a foot or ankle injury, rest to avoid walking on the injured ankle or foot, use ice packs, wrap the foot or ankle with compression bandage, and elevate the foot on a stool or pillow. If swelling and pain is severe or doesn't improve with home treatment, see your doctor.

Lymphedema. This is a collection of lymphatic fluid in the tissues that can develop because of the absence of or problems with the lymph vessels or after the removal of lymph nodes. Lymph is a protein-rich fluid that normally travels along an extensive network of vessels and capillaries. It is filtered through the lymph nodes, which trap and destroy unwanted substances, such as bacteria. When there is a problem with the vessels or lymph nodes, however, the fluid's movement can be blocked. Untreated, lymph buildup can impair wound healing and lead to infection and deformity. Lymphedema is common following radiation therapy or removal of the lymph nodes in patients with cancer. If you have undergone cancer treatment and experience swelling, see your doctor right away.

Venous insufficiency. Swelling of the ankles and feet is often an early symptom of venous insufficiency, a condition in which blood inadequately moves up the veins from the legs and feet up to the heart. Normally, the veins keep blood flowing upward with one-way valves. When these valves become damaged or weakened, the blood leaks back down the vessels and fluid is retained in the soft tissue of the lower legs, especially the ankles and feet. Chronic venous insufficiency can lead to skin changes, skin ulcers, and infection. If you experience signs of venous insufficiency you should see your doctor.

Infection. Swelling in the feet and ankles can be a sign of infection. People with diabetic neuropathy or other nerve problems of the feet are at greater risk for foot infections. If you have diabetes, it is important to inspect feet daily for blisters and sores, because nerve damage can blunt the pain sensation and foot problems can progress quickly. If you notice a swollen foot or blister that appears to be infected, contact your doctor right away.

Blood clot. Blood clots that form in the veins of the legs can stop the return flow of blood from the legs back up to the heart and cause swelling in the ankles and feet. Blood clots can be either superficial (occurring in the veins just beneath the skin), or deep (a condition known as deep vein thrombosis). Deep clots can block one or more of the major veins of the legs. These blood clots can be life-threatening if they break loose and travel to the heart and lungs. If you have swelling in one leg, along with pain, low-grade fever, and possibly a change in color of the affected leg, call your doctor immediately. Treatment with blood thinners may be necessary.

Heart, liver, or kidney disease. Sometimes swelling can indicate a problem such as heart, liver, or kidney disease. Ankles that swell in the evening could be a sign of retaining salt and water because of right-sided heart failure. Kidney disease can also cause foot and ankle swelling. When kidneys are not functioning properly, fluid can build up in the body. Liver disease can affect the liver's production of a protein called albumin, which keeps the blood from leaking out of the blood vessels into the surrounding tissues. Inadequate albumin production can lead to fluid leakage. Gravity causes fluid to accumulate more in the feet and ankles, but fluid can also accumulate in the abdomen and chest. If your swelling is accompanied by other symptoms, including fatigue, loss of appetite, and weight gain, see your doctor right away. If you feel short of breath or have chest pain, pressure, or tightness, call 911.

Medication side effect. Many drugs can cause swelling in the feet and ankles as a possible side effect. They include:

• Hormones such as estrogen (found in oral contraceptives and hormone replacement therapy) and testosterone
• Calcium channel blockers, a type of blood pressure medication, which includes nifedipine (Adalat, Afeditab, Nifediac, Nifedical, Procardia), amlodipine (Norvasc), diltiazem (Cardizem, Cartia, Dilacor, Diltia, Tiazac), felodipine (Plendil), and verapamil (Calan, Covera-HS, Isoptin, Isoptin SR, Verelan)
• Steroids, including androgenic and anabolic steroids and corticosteroids such as prednisone
• Antidepressants, including: tricyclics, such as nortriptyline (Pamelor, Aventyl), desipramine (Norpramin), and amitriptyline (Elavil, Endep, Vanatrip); and monoamine oxidase (MAO) inhibitors such as phenelzine (Nardil) and tranylcypromine (Parnate)
• Non-steroidal anti-inflammatory drugs (NSAIDs)
• Diabetes medications.

If you suspect swelling may be related to a drug you are taking, speak to your Dr. Raymond A. DiPretoro, Jr., at Advanced Foot & Ankle Center. Although the benefits of the drug may be worth enduring some swelling, more severe swelling could make it necessary to change the medication or its dosage.

Achilles Tendinitis

Achilles Tendinitis

Achilles tendinitis is a common condition that causes pain along the back of the leg near the heel.

The Achilles tendon is the largest tendon in the body. It connects your calf muscles to your heel bone and is used when you walk, run, and jump.

Although the Achilles tendon can withstand great stresses from running and jumping, it is also prone to tendinitis, a condition associated with overuse and degeneration.

Description

Simply defined, tendinitis is inflammation of a tendon. Inflammation is the body's natural response to injury or disease, and often causes swelling, pain, or irritation. There are two types of Achilles tendinitis, based upon which part of the tendon is inflamed.

Noninsertional Achilles tendinitis

Noninsertional Achilles Tendinitis

In noninsertional Achilles tendinitis, fibers in the middle portion of the tendon have begun to break down with tiny tears (degenerate), swell, and thicken.

Tendinitis of the middle portion of the tendon more commonly affects younger, active people.

Insertional Achilles Tendinitis

Insertional Achilles tendinitis involves the lower portion of the heel, where the tendon attaches (inserts) to the heel bone.

In both noninsertional and insertional Achilles tendinitis, damaged tendon fibers may also calcify (harden). Bone spurs (extra bone growth) often form with insertional Achilles tendinitis.
Tendinitis that affects the insertion of the tendon can occur at any time, even in patients who are not active.

Insertional Achilles tendinitis

Cause

Achilles tendinitis is typically not related to a specific injury. The problem results from repetitive stress to the tendon. This often happens when we push our bodies to do too much, too soon, but other factors can make it more likely to develop tendinitis, including:

A bone spur that has developed where the tendon attaches to the heel bone.

• Sudden increase in the amount or intensity of exercise activity—for example, increasing the distance you run every day by a few miles without giving your body a chance to adjust to the new distance
• Tight calf muscles—Having tight calf muscles and suddenly starting an aggressive exercise program can put extra stress on the Achilles tendon
• Bone spur—Extra bone growth where the Achilles tendon attaches to the heel bone can rub against the tendon and cause pain

Symptoms

Common symptoms of Achilles tendinitis include:

• Pain and stiffness along the Achilles tendon in the morning
• Pain along the tendon or back of the heel that worsens with activity
• Severe pain the day after exercising
• Thickening of the tendon
• Bone spur (insertional tendinitis)
• Swelling that is present all the time and gets worse throughout the day with activity

If you have experienced a sudden "pop" in the back of your calf or heel, you may have ruptured (torn) your Achilles tendon. See Dr. Raymond A. DiPretoro, Jr.  immediately if you think you may have torn your tendon.

Podiatrist Examination

After you describe your symptoms and discuss your concerns, Dr. Raymond A.DiPretoro, Jr. will examine your foot and ankle.  Dr. DiPretoro will look for these signs:

• Swelling along the Achilles tendon or at the back of your heel
• Thickening or enlargement of the Achilles tendon
• Bony spurs at the lower part of the tendon at the back of your heel (insertional tendinitis)
• The point of maximum tenderness
• Pain in the middle of the tendon, (noninsertional tendinitis)
• Pain at the back of your heel at the lower part of the tendon (insertional tendinitis)
• Limited range of motion in your ankle—specifically, a decreased ability to flex your foot

Tests

 The Doctors at Advanced Foot & Ankle Center may order imaging tests to make sure your symptoms are caused by Achilles tendinitis.

X-rays

X-ray tests provide clear images of bones. X-rays can show whether the lower part of the Achilles tendon has calcified, or become hardened. This calcification indicates insertional Achilles tendinitis. In cases of severe noninsertional Achilles tendinitis, there can be calcification in the middle portion of the tendon, as well.

Magnetic Resonance Imaging (MRI)

Although magnetic resonance imaging (MRI) is not necessary to diagnose Achilles tendinitis, it is important for planning surgery. An MRI scan can show how severe the damage is in the tendon. If surgery is needed, your doctor will select the procedure based on the amount of tendon damage.

Treatment

Nonsurgical Treatment

In most cases, nonsurgical treatment options will provide pain relief, although it may take a few months for symptoms to completely subside. Even with early treatment, the pain may last longer than 3 months. If you have had pain for several months before seeking treatment, it may take 6 months before treatment methods take effect.

Rest. The first step in reducing pain is to decrease or even stop the activities that make the pain worse. If you regularly do high-impact exercises (such as running), switching to low-impact activities will put less stress on the Achilles tendon. Cross-training activities such as biking, elliptical exercise, and swimming are low-impact options to help you stay active.
Ice. Placing ice on the most painful area of the Achilles tendon is helpful and can be done as needed throughout the day. This can be done for up to 20 minutes and should be stopped earlier if the skin becomes numb. A foam cup filled with water and then frozen creates a simple, reusable ice pack. After the water has frozen in the cup, tear off the rim of the cup. Then rub the ice on the Achilles tendon. With repeated use, a groove that fits the Achilles tendon will appear, creating a "custom-fit" ice pack.
Non-steroidal anti-inflammatory medication. Drugs such as ibuprofen and naproxen reduce pain and swelling. They do not, however, reduce the thickening of the degenerated tendon. Using the medication for more than 1 month should be reviewed with your primary care doctor.
Exercise. The following exercise can help to strengthen the calf muscles and reduce stress on the Achilles tendon.

• Calf stretch
  Lean forward against a wall with one knee straight and the heel on the ground. Place the other leg in front, with the knee bent. To stretch the calf muscles and the heel cord, push your hips toward the wall in a controlled fashion. Hold the position for 10 seconds and relax. Repeat this exercise 20 times for each foot. A strong pull in the calf should be felt during the stretch.

Physical Therapy. Physical therapy is very helpful in treating Achilles tendinitis. It has proven to work better for noninsertional tendinitis than for insertional tendinitis.
Eccentric Strengthening Protocol. Eccentric strengthening is defined as contracting (tightening) a muscle while it is getting longer. Eccentric strengthening exercises can cause damage to the Achilles tendon if they are not done correctly. At first, they should be performed under the supervision of a physical therapist. Once mastered with a therapist, the exercises can then be done at home. These exercises may cause some discomfort, however, it should not be unbearable.

• Bilateral heel drop
  Stand at the edge of a stair, or a raised platform that is stable, with just the front half of your foot on the stair. This position will allow your heel to move up and down without hitting the stair. Care must be taken to ensure that you are balanced correctly to prevent falling and injury. Be sure to hold onto a railing to help you balance.
Lift your heels off the ground then slowly lower your heels to the lowest point possible. Repeat this step 20 times. This exercise should be done in a slow, controlled fashion. Rapid movement can create the risk of damage to the tendon. As the pain improves, you can increase the difficulty level of the exercise by holding a small weight in each hand.

• Single leg heel drop
  This exercise is performed similarly to the bilateral heel drop, except that all your weight is focused on one leg. This should be done only after the bilateral heel drop has been mastered.

Cortisone injections. Cortisone, a type of steroid, is a powerful anti-inflammatory medication. Cortisone injections into the Achilles tendon are rarely recommended because they can cause the tendon to rupture (tear).
Supportive shoes and orthotics. Pain from insertional Achilles tendinitis is often helped by certain shoes, as well as orthotic devices. For example, shoes that are softer at the back of the heel can reduce irritation of the tendon. In addition, heel lifts can take some strain off the tendon.
Heel lifts are also very helpful for patients with insertional tendinitis because they can move the heel away from the back of the shoe, where rubbing can occur. They also take some strain off the tendon. Like a heel lift, a silicone Achilles sleeve can reduce irritation from the back of a shoe.
If your pain is severe, your doctor may recommend a walking boot for a short time. This gives the tendon a chance to rest before any therapy is begun. Extended use of a boot is discouraged, though, because it can weaken your calf muscle.
Extracorporeal shockwave therapy (ESWT). During this procedure, high-energy shockwave impulses stimulate the healing process in damaged tendon tissue. ESWT has not shown consistent results and, therefore, is not commonly performed.
ESWT is noninvasive—it does not require a surgical incision. Because of the minimal risk involved, ESWT is sometimes tried before surgery is considered.

Surgical Treatment

Surgery should be considered to relieve Achilles tendinitis only if the pain does not improve after 6 months of nonsurgical treatment. The specific type of surgery depends on the location of the tendinitis and the amount of damage to the tendon.

Gastrocnemius recession. This is a surgical lengthening of the calf (gastrocnemius) muscles. Because tight calf muscles place increased stress on the Achilles tendon, this procedure is useful for patients who still have difficulty flexing their feet, despite consistent stretching.
In gastrocnemius recession, one of the two muscles that make up the calf is lengthened to increase the motion of the ankle. The procedure can be performed with a traditional, open incision or with a smaller incision and an endoscope—an instrument that contains a small camera. Your doctor will discuss the procedure that best meets your needs.
Complication rates for gastrocnemius recession are low, but can include nerve damage.
Gastrocnemius recession can be performed with or without débridement, which is removal of damaged tissue.
Débridement and repair (tendon has less than 50% damage). The goal of this operation is to remove the damaged part of the Achilles tendon. Once the unhealthy portion of the tendon has been removed, the remaining tendon is repaired with sutures, or stitches to complete the repair.
In insertional tendinitis, the bone spur is also removed. Repair of the tendon in these instances may require the use of metal or plastic anchors to help hold the Achilles tendon to the heel bone, where it attaches.
After débridement and repair, most patients are allowed to walk in a removable boot or cast within 2 weeks, although this period depends upon the amount of damage to the tendon.
Débridement with tendon transfer (tendon has greater than 50% damage). In cases where more than 50% of the Achilles tendon is not healthy and requires removal, the remaining portion of the tendon is not strong enough to function alone. To prevent the remaining tendon from rupturing with activity, an Achilles tendon transfer is performed. The tendon that helps the big toe point down is moved to the heel bone to add strength to the damaged tendon. Although this sounds severe, the big toe will still be able to move, and most patients will not notice a change in the way they walk or run.
Depending on the extent of damage to the tendon, some patients may not be able to return to competitive sports or running.
Recovery. Most patients have good results from surgery. The main factor in surgical recovery is the amount of damage to the tendon. The greater the amount of tendon involved, the longer the recovery period, and the less likely a patient will be able to return to sports activity.
Physical therapy is an important part of recovery. Many patients require 12 months of rehabilitation before they are pain-free.
Complications. Moderate to severe pain after surgery is noted in 20% to 30% of patients and is the most common complication. In addition, a wound infection can occur and the infection is very difficult to treat in this location.

Care of the Diabetic Foot!

Care of the Diabetic Foot

Diabetic foot problems are a major health concern and are a common cause of hospitalization.

Most foot problems that people with diabetes face arise from two serious complications of the disease: nerve damage and poor circulation. The lack of feeling and poor blood flow can allow a small blister to progress to a serious infection in a matter of days. Chronic nerve damage (neuropathy) can cause dry and cracked skin, which provides an opportunity for bacteria to enter and cause infection.

The consequences can range from hospitalization for antibiotics to amputation of a toe or foot. For people with diabetes, careful, daily inspection of the feet is essential to overall health and the prevention of damaging foot problems.

General Care of the Diabetic Foot

• Never walk barefoot. The nerve damage decreases sensation so you may not notice that little pebbles or objects have gotten stuck in your foot. This can lead to a massive infection. Always wearing shoes or slippers reduces this risk.
• Wash your feet every day with mild soap and warm water. Test the water temperature with your hand first. Do not soak your feet. When drying them, pat each foot with a towel rather than rubbing vigorously. Be careful drying between your toes.
• Use lotion to keep the skin of your feet soft and moist. This prevents dry skin cracks and decreases the risk of infection. Do not put lotion between the toes.
• Trim your toe nails straight across. Avoid cutting the corners. Use a nail file or emery board. If you find an ingrown toenail, see your doctor. Good medical care is important in preventing infections.
• Do not use antiseptic solutions, drugstore medications, heating pads, or sharp instruments on your feet. Do not put your feet on radiators or in front of the fireplace.
• Always keep your feet warm. Wear loose socks to bed. Do not get your feet wet in snow or rain. Wear warm socks and shoes in winter.
• Do NOT smoke. Smoking damages blood vessels and decreases the ability of the body to deliver oxygen. In combination with diabetes, it significantly increases your risk of amputation — not only of the feet, but can include the hands, as well.

Inspection

• Inspect your feet every day.
• Look for puncture wounds, bruises, pressure areas, redness, warmth, blisters, ulcers, scratches, cuts, and nail problems.
• Get someone to help you, or use a mirror if you are unable to do it alone. You may not feel that damage has occurred to the skin. Inspecting for skin breakdown is crucial.
• Look at and feel each foot for swelling. Swelling in one of the feet and not the other is an early sign that you may be experiencing early stages of Charcot (pronounced "sharko") foot. This is a unique problem that can occur in people with nerve damage. It can destroy the bones and joints.
• Examine the bottoms of your feet and toes. Check the six major locations on the bottom of each foot:
• The tip of the big toe
• The base of the little toes
• The base of the middle toes
• The heel
• The outside edge of the foot
• Across the ball of the foot

Shoewear

Choose and wear your shoes carefully. A poor fitting shoe can cause an ulcer and lead to an infection.

• Buy new shoes late in the day when your feet are larger. Buy shoes that are comfortable without a "breaking in" period.
• Check how your shoe fits in width, length, back, bottom of heel, and sole. Have your feet measured every time you buy new shoes. Your foot will change shape over the years and you may not be the same shoe size you were 5 years ago.
• Avoid pointed-toe styles and high heels. Try to get shoes made with leather upper material and deep toe boxes.
• Wear new shoes for only 2 hours or less at a time. Do not wear the same pair every day.
• Inspect the inside of each shoe before putting it on. Do not lace your shoes too tightly or loosely.
• Avoid long walks without taking a break, removing your shoes and socks and checking for signs of pressure (redness) or ulcers.

Orthotics

Insurance companies frequently will cover the cost of orthotics for people with diabetes. They understand how important it is to minimize the risk of a pressure sore in these patients. Discuss this with your primary doctor or orthopedic surgeon.

An accommodative orthotic made from a soft material called plastizote is commonly prescribed. The orthotics should not be hard, as this will increase the risk of a pressure ulcer. The orthotic can be transferred from shoe to shoe and should be used at all times when standing or walking.

Osteomyelitis (bone Infection)

Definition

Osteomyelitis is an infection in a bone. Infections can reach a bone by traveling through the bloodstream or spreading from nearby tissue. Osteomyelitis can also begin in the bone itself if an injury exposes the bone to germs.

In children, osteomyelitis most commonly affects the long bones of the legs and upper arm, while adults are more likely to develop osteomyelitis in the bones that make up the spine (vertebrae). People who have diabetes may develop osteomyelitis in their feet if they have foot ulcers.

Once considered an incurable condition, osteomyelitis can be successfully treated today. Most people require surgery to remove parts of the bone that have died — followed by strong antibiotics, often delivered intravenously, typically for at least six weeks.

Symptoms

Signs and symptoms of osteomyelitis include:

• Fever or chills
• Irritability or lethargy in young children
• Pain in the area of the infection
• Swelling, warmth and redness over the area of the infection

Sometimes osteomyelitis causes no signs and symptoms or has signs and symptoms that are difficult to distinguish from other problems.

When to see a doctor. See your doctor if you experience worsening bone pain along with fever. If you're at risk of infection because of a medical condition or recent surgery or injury, see your doctor right away if you notice signs and symptoms of an infection.

Most cases of osteomyelitis are caused by staphylococcus bacteria, a type of germ commonly found on the skin or in the nose of even healthy individuals.

Germs can enter a bone in a variety of ways, including:

• Via the bloodstream. Germs in other parts of your body — for example, from pneumonia or a urinary tract infection — can travel through your bloodstream to a weakened spot in a bone. In children, osteomyelitis most commonly occurs in the softer areas, called growth plates, at either end of the long bones of the arms and legs.
• From a nearby infection. Severe puncture wounds can carry germs deep inside your body. If such an injury becomes infected, the germs can spread into a nearby bone.
• Direct contamination. This may occur if you have broken a bone so severely that part of it is sticking out through your skin. Direct contamination can also occur during surgeries to replace joints or repair fractures.

Risk Factors

Your bones are normally resistant to infection. For osteomyelitis to occur, a situation that makes your bones vulnerable must be present.

Recent injury or orthopedic surgery A severe bone fracture or a deep puncture wound gives infections a route to enter your bone or nearby tissue. Surgery to repair broken bones or replace worn joints also can accidentally open a path for germs to enter a bone. Deep animal bites also can provide a pathway for infection.

Circulation disorders When blood vessels are damaged or blocked, your body has trouble distributing the infection-fighting cells needed to keep a small infection from growing larger. What begins as a small cut can progress to a deep ulcer that may expose deep tissue and bone to infection. Diseases that impair blood circulation include:

• Poorly controlled diabetes
• Peripheral arterial disease, often related to smoking
• Sickle cell disease

Problems requiring intravenous lines or cathetersThere are a number of conditions that require the use of medical tubing to connect the outside world with your internal organs. However, this tubing can also serve as a way for germs to get into your body, increasing your risk of an infection in general, which can lead to osteomyelitis. Examples of when this type of tubing might be used include:

• Dialysis machines
• Urinary catheters
• Long-term intravenous tubing, sometimes called central lines

Conditions that impair the immune systemIf your immune system is affected by a medical condition or medication, you have a greater risk of osteomyelitis. Factors that may suppress your immune system include:

• Chemotherapy
• Poorly controlled diabetes
• Having had an organ transplant
• Needing to take corticosteroids or drugs called tumor necrosis factor (TNF) inhibitors.

For unclear reasons, people with HIV/AIDS don't seem to have an increased risk of osteomyelitis.

Illicit drugs People who inject illicit drugs are more likely to develop osteomyelitis because they typically use nonsterile needles and don't sterilize their skin before injections.

Complications

Osteomyelitis complications may include:

• Bone death (osteonecrosis). An infection in your bone can impede blood circulation within the bone, leading to bone death. Your bone can heal after surgery to remove small sections of dead bone. If a large section of your bone has died, however, you may need to have that limb amputated to prevent spread of the infection.
• Septic arthritis. In some cases, infection within bones can spread into a nearby joint.
• Impaired growth. In children, the most common location for osteomyelitis is in the softer areas, called growth plates, at either end of the long bones of the arms and legs. Normal growth may be interrupted in infected bones.
• Skin cancer. If your osteomyelitis has resulted in an open sore that is draining pus, the surrounding skin is at higher risk of developing squamous cell cancer.

Preparing for your Podiatry Appointment

While you might initially bring your signs and symptoms to the attention of your family doctor, he or she may refer you to a doctor specializing in infectious diseases or to an Podiatric surgeon.

Here's some information to help you get ready for your appointment, and what to expect from your Podiatrist, Dr. Raymond A. DiPretoro, Jr..

What you can do

• Write down any symptoms you're experiencing, including any that may seem unrelated to the reason for which you scheduled the appointment.
• Make a list of all medications, vitamins or supplements that you're taking.
• Write down questions to ask your doctor.

For osteomyelitis, some basic questions to ask your doctor include:

• What's the most likely cause of my symptoms?
• Are there other possible causes for my symptoms?
• What kinds of tests do I need? Do these tests require any special preparation?
• What treatments are available, and which do you recommend?
• Will surgery be necessary?
• What types of side effects can I expect from treatment?
• I have other health conditions. How can I best manage these conditions together?
• Is there a generic alternative to the medicine you're prescribing?
• Are there any brochures or other printed material that I can take home with me? What websites do you recommend visiting?

What to expect from your Podiatrist

During the physical exam, Dr. Raymond A. DiPretoro, Jr. may feel the area around the affected bone for any tenderness, swelling or warmth. If you have a foot ulcer, Dr. DiPretoro may use a dull probe to determine the proximity of the underlying bone.

Your doctor is likely to ask you a number of questions, such as:

• When did you first begin experiencing symptoms?
• Do you have a fever or chills?
• Does anything make your symptoms better or worse?
• Have you had any cuts, scrapes or other injuries lately?
• Have you had any surgery recently?
• Have you ever had a joint replaced? Or have you had surgical correction of a broken bone?
• Do you have diabetes? Do you have any foot ulcers?

Plantar Warts

What are Warts?

Warts are one of several soft tissue conditions of the foot that can be quite painful. They are caused by a virus and can appear anywhere on the skin. Those that appear on the sole of the foot are called plantar warts. Children, especially teenagers, tend to be more susceptible to warts than adults. Some people seem to be immune to warts.

Causes

The virus that causes warts generally invades the skin through small or invisible cuts and abrasions. The plantar wart is often contracted by walking barefoot on dirty surfaces or littered ground where the virus is lurking. The causative virus thrives in warm, moist environments, making infection a common occurrence in communal bathing facilities.

If left untreated, warts can grow to an inch or more in circumference and can spread into clusters of several warts; these are often called mosaic warts. Like any other infectious lesion, plantar warts are spread by touching, scratching, or even by contact with skin shed from another wart. The wart may also bleed, creating another route for spreading. Occasionally, warts can spontaneously disappear after a short time, and, just as frequently, they can recur in the same location.

Symptoms/Identification

Most warts are harmless, even though they may be painful. They are often mistaken for corns or calluses, which are layers of dead skin that build up to protect an area which is being continuously irritated. The wart, however, is a viral infection.

Plantar warts tend to be hard and flat, with a rough surface and well-defined boundaries; warts are generally raised and fleshier when they appear on the top of the foot or on the toes. Plantar warts are often gray or brown (but the color may vary), with a center that appears as one or more pinpoints of black. It is important to note that warts can be very resistant to treatment and have a tendency to reoccur.

When plantar warts develop on the weight-bearing areas of the foot—the ball of the foot, or the heel, for example—they can be the source of sharp, burning pain. Pain occurs when weight is brought to bear directly on the wart, although pressure on the side of a wart can create equally intense pain.

Home Care

Self-treatment is generally not advisable. Over-the-counter preparations contain acids or chemicals that destroy skin cells, and it takes an expert to destroy abnormal skin cells (warts) without also destroying surrounding healthy tissue. Self-treatment with such medications especially should be avoided by people with diabetes and those with cardiovascular or circulatory disorders. Never use these medications in the presence of an active infection.

When to Visit a Podiatrist

It is wise to consult Dr. Raymond A. DiPretoro, Jr., when any suspicious growth or eruption is detected on the skin of the foot in order to ensure a correct diagnosis. It is possible for a variety of more serious lesions to appear on the foot, including malignant lesions such as carcinomas and melanomas. Although rare, these conditions can sometimes be misidentified as a wart.

Diagnosis and Treatment

It is possible that your podiatric physician will prescribe and supervise your use of a wart-removal preparation. More likely, however, removal of warts by a simple surgical procedure, performed under local anesthetic, may be indicated.

Lasers have become a common and effective treatment. A procedure known as CO2 laser cautery is performed under local anesthesia either in your podiatrist’s office surgical setting or an outpatient surgery facility. The laser reduces post-treatment scarring and is a safe form for eliminating wart lesions.

Prevention

• Avoid walking barefoot, except on sandy beaches.
• Change shoes and socks daily.
• Keep feet clean and dry.
• Check children's feet periodically.
• Avoid direct contact with warts—from other persons or from other parts of the body.
• Do not ignore growths on, or changes in, your skin.
• Visit your podiatric physicians at Advanced Foot & Ankle Center, as part of your annual health checkup.

The Diabetic (Charcot) Foot!

Diabetic (Charcot) Foot

Diabetes is a condition of elevated blood sugar that affects about 6 percent of the population in the United States, or about 16 million people. Diabetic foot problems are a major health concern and are a common cause of hospitalization.

Most foot problems that people with diabetes face arise from two serious complications of the disease: nerve damage and poor circulation. One of the more critical foot problems these complications can cause is Charcot arthropathy, which can deform the shape of the foot and lead to disability.

There are treatment options for the wide range of diabetic foot problems. The most effective treatment, however, is prevention. For people with diabetes, careful, daily inspection of the feet is essential to overall health and the prevention of damaging foot problems.

Description

A severely infected big toe. This infection began two days previously as a small blister at the tip of the toe.

Nerve damage (neuropathy) is a complication of diabetes that leads to a loss of sensation in the feet. Some people with diabetes can no longer feel when something has irritated or even punctured the skin. A wound as small as a blister can progress to a serious infection in a matter of days.

Diabetes also damages blood vessels, decreasing the blood flow to the feet. Poor circulation weakens bone, and can cause disintegration of the bones and joints in the foot and ankle. As a result, people with diabetes are at a high risk for breaking bones in the feet.

When a diabetic fractures a bone in the foot, he or she may not realize it because of nerve damage. Continuing to walk on the injured foot results in more severe fractures and joint dislocations. Sharp edges of broken bone within the foot can point downward toward the ground, increasing the risk of chronic foot sores from the abnormal pressure.

(Left) This patient with Charcot of the ankle has developed a deformity that places abnormal pressure on the outside of the ankle. (Right)This pressure has led to the development of a chronic sore (ulcer) that can be extremely difficult to treat.

The combination of bone disintegration and trauma can warp and deform the shape of the foot. This condition is called Charcot arthropathy, and is one of the most serious foot problems that diabetics face.

This patient with Charcot arthropathy has a severe deformity caused by the breakdown of the ankle joint.

Reproduced from Harrelson JM: The diabetic foot: Charcot arthropathy. Instr Course Lect 1993; 42;141-146

Symptoms

Although a patient with Charcot arthropathy typically will not have much pain, they may have other symptoms.

• The most sensitive sign of early Charcot foot is swelling of the foot. This can occur without an obvious injury.
• Redness of the foot can also occur in the early stages.
• The swelling, redness, and changes to the bone that are seen on x-ray may be confused for a bone infection. A bone infection is very unlikely if the skin is intact and there is no ulcer present.

Podiatrist Examination

Medical History and Physical Examination

Dr. Raymond A. DiPretoro, Jr.,  will talk with you about your general health as well as any symptoms you may have. If you know how you may have injured your foot, he will also want to discuss that.

After discussing your symptoms and medical history, Dr. DiPretoro will carefully examine your foot.

Imaging Tests

X-rays. These imaging tests provide detailed pictures of dense structures, like bone. In the very early setting of Charcot, the x-rays may be normal. If the condition has progressed to the intermediate stages, multiple fractures and dislocations of the joints can be seen in an x-ray.

The patient shown in the x-ray had noticed swelling of the foot for approximately 3 weeks without any known injury. The x-ray shows several fractures (arrowheads) and a dislocation of the first metatarsal (arrow). This severe an injury is typically seen only after a high-energy trauma in patients without diabetes.

These x-rays show Charcot changes to the ankle after the patient fell 4 weeks earlier. This resulted in several bones shifting position.(Right) The talus (red arrowhead) is normally located below the tibia. As a result of Charcot, the talus has shifted forward and the tibia has dropped down. The curved line indicates the abnormal position of the lower end of the tibia.

Magnetic resonance imaging (MRI) and ultrasound. These studies can create better images of soft tissues of the foot and ankle. These may be ordered if your doctor suspects a bone infection. If there is not a break in the skin, infection of the bone is extremely rare.

Bone scan/indium scan. A bone scan is a nuclear medicine test that is very effective in determining whether there is a bone infection. There are different types of bone scans, and the doctor must determine which type(s) are best to use for a particular problem. An indium scan is a specialized test that involves placing a marker on white blood cells. These cells are traced to learn whether they are going to the bone to fight an infection.
Both Charcot foot and bone infection will cause a positive bone scan (increased activity). However, only an infection will show significantly increased activity on the indium scan.

Treatment

The goal of treatment for Charcot arthropathy is to heal the broken bones, as well as prevent further deformity and joint destruction.

Nonsurgical Treatment

Casting. The early stages of Charcot are usually treated with a cast or cast boot to protect the foot and ankle. The use of a cast is very effective in reducing the swelling and protecting the bones.

Casting requires that the patient not put weight on the foot until the bones begin to heal. Crutches, a knee-walker device, or a wheelchair are usually necessary. Healing can sometimes take 3 months or more. The cast will usually be changed every week or two to make sure that it continues to "fit" the leg as the swelling goes down.
Custom shoes. After the initial swelling has decreased and the bones begin to fuse back together, a specialized custom walking boot or diabetic shoe may be recommended. The specialized shoe is designed to decrease the risk of ulcers (sores that do not heal). Some diabetics may not be able to wear regular, over-the-counter shoes because they do not fit the deformed foot correctly.

Surgical Treatment

Surgery may be recommended if the foot deformity puts the patient at a high risk for ulcers, or if protective shoewear is not effective. Unstable fractures and dislocations also require surgery to heal.

• Mild deformity with tightness at the heel. In some cases, the deformity is mild and associated with tightness at the back of the heel. Ulcers in the front of the foot that do not respond to a period of casting and protective shoewear, may be treated through Achilles tendon lengthening. Surgically lengthening the tendon that runs down the back of the leg and attaches to the back of the heel decreases the pressure on the midfoot and front of the foot. This allows the ulcer to heal and reduces the chance that it will return.
• Bony prominence on the bottom of the foot. A more severe deformity is the appearance of a very large bony bump on the bottom of the foot. If this cannot be addressed with shoe modification, it requires surgery. The type of surgery depends on the stability of the bones and joints in the foot.
• Stable deformity. Surgery involves a simple removal of the prominent bone by shaving it off.
• Unstable deformity. When the bones are too loose at the sight of the prominence, a simple removal of the bump will not be effective. The loose bones will simply move and a new prominence will develop. In this situation, fusion and repositioning of the bones is needed.
Fractures that occur in the softer bone of diabetics are typically more complex. Operations to fix them generally involve more hardware (plates and screws) than would normally be required in people without diabetes. The screws and plates may even be placed across normal joints to provide added stability.



(Top) In this x-ray taken from the side, the patient has unstable Charcot of the back of the foot (hindfoot). The dislocation of the joints is seen where the two bones in the back of the foot do not line up (arrowhead). (Bottom) A complex realignment and fusion was performed to prevent the patient from developing a prominence and ulceration.
This operation is extremely difficult to perform and carries a higher risk of wound complications, infections, and amputation, compared to routine foot and ankle fracture surgery.
After this type of operation, there is typically a period of no weight on the foot for at least 3 months. Placing weight on the foot early and failing to follow the doctor's instructions will likely lead to complications, such as the return of the deformity or even worsening of the deformity.

• Ankle deformity. Charcot of the ankle is difficult to treat simply with a brace or shoe and commonly requires surgical fusion of both the ankle and the joint below the ankle (subtalar) to hold the foot straight. Given the amount of destruction of the bone and the poor quality of the soft tissue, the risk that the bone will not heal and the risk of infection are very high. Amputation may be required, either as the first operation or to salvage a fusion that has not healed or has became infected.

This patient developed an infection of the bone nine months after an ankle joint fusion to reconstruct a Charcot deformity. After attempts to cure the infection were unsuccessful, it was necessary to amputate his foot and ankle. He returned to walking pain-free with a prosthesis.

Conclusion

To ensure the best outcome from treatment, it is essential that the patient follows Dr. Raymond A. DiPretoro's instructions regarding when it is safe to put weight on the injured foot. In addition, the sooner Charcot arthropathy is diagnosed and treated, the better the final outcome. Patients must carefully inspect both feet everyday and control their blood sugar levels. Both responsibilities are important in recognizing Charcot foot early, and in avoiding future complications.

Please call our office, Advanced Foot & Ankle Center immediately should you have any of these symptoms!

Athlete's Foot: Signs and Symptoms

What are the symptoms and signs of athlete's foot?

Many individuals with athlete's foot have no symptoms at all and do not even know they have an infection. Many may think they simply have dry skin on the soles of their feet. Common symptoms of athlete's foot typically include various degrees of itching and burning. The skin may frequently peel, and in particularly severe cases, there may be some cracking, pain, and bleeding as well. Rarely, athlete's foot can blister.

What does athlete's foot look like?

Most cases of athlete's foot are barely noticeable with just slightly dry, flaky skin. More extensive athlete's foot may look like red, peeling, dry skin areas on one or both soles of the feet. Sometimes the dry flakes may spread onto the sides and tops of the feet. Most commonly, the rash is localized to just the bottoms of the feet. The space between the fourth and fifth toes also may have some moisture, peeling, and dry flakes.

There are three common types of athlete's foot: (1) soles of the feet, also called "moccasin" type; (2) between the toes, also called "interdigital" type; and (3) inflammatory type or blistering.

Unusual cases may look like small or large blisters of the feet (called bullous tinea pedis), thick patches of dry, red skin, or calluses with redness. Sometimes, it may look like just mild dry skin without any redness or inflammation.

Athlete's foot may present as a rash on one or both feet and even involve the hand. A "two feet and one hand" presentation is a very common presentation of athlete's foot, especially in men. Hand fungal infections are called tinea manuum. The exact cause of why the infection commonly only affects one hand is not known.

Athlete's foot may also be seen along with ringworm of the groin (especially in men) or hand(s). It is helpful to examine the feet whenever there is a fungal groin rash called tinea cruris. It is important to treat all areas of fungal infection at one time to avoid reinfection. Simply treating the soles and ignoring the concurrent fungal infection of toenails may result in recurrences of athlete's foot. It is important to evaluate and address all potential sources of fungal infection.