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            It is generally accepted that Diabetes is a serious metabolic disease that puts its sufferers at risk for a number of health problems, especially of the foot and ankle. While Diabetic Peripheral Neuropathy is a chemically damaging aspect of the disease there are mechanical aspects that also play a role in the foot of a diabetic patient. One such condition is the development of an Equinus deformity.

A Radiograph from truelok.net that shows an Equinus deformity perfectly.

         This deformity gets its name from the root word equus, which is the family of horse like animals…which if you notice, all stand on their toes! Toe-walking is a symptom of the Equinus deformity and is due to tight calf muscles, specifically the Gastrocnemius, which contributes to the formation of the Achille’s Tendon. Due to the attachment onto the Calcaneus (Heel bone) the Achille’s Tendon pulls the back of the foot upward when tight, which leads to the patient putting more weight onto the front of their foot in toe-walking. 

A diagram demonstrating the mechanics of the foot and ankle joints from oandp.com

         This displacement of weight causes the foot to compensate which causes other deformities like Plantar Fasciitis, Hallux Limitus, Metatarsalgia, and Tendonitis in a few places in the foot. In the Diabetic foot conditions like ulcers under the metatarsals and even Charcot foot are a major cause of concern for the Podiatric patient and physician.

Fortunately, there are plenty of options for the treatment of this deformity and many are quite simple yet effective.

-       Stretching exercises can help patients with the tension in their Achille’s Tendon.

-       Orthotics or Heel inserts may also help elevate the back of the foot and reduce tension on the tendon.

-       Surgical intervention in the form of an Endoscopic Gastrocnemius Resection (EGR) is a minimally invasive option that is usually very successful in the treatment of Equinus deformity.

        Equinus deformity is a common problem and you should be evaluated for this condition by your Podiatrist when seeking the cause of your foot pain!

Picture of Silfverskiold test from podiatrytoday.com

        A simple tool called the Silfverskiold Test is used to determine the amount of movement in the patient’s  dorsiflexion (pointing the toes upward) of the foot both with the leg extended and flexed as shown below. A marked decrease in dorsiflexion with an extended leg indicates excessive tension in the Achille’s Tendon and a possible candidate for EGR. 

        Exercise is important to maintaining a healthy lifestyle and will almost never be discouraged by your doctor. But, like for most things, following a plan and becoming acclimated will be far more beneficial than jumping in too far, too soon! By building up your body’s tolerance to the rigors of your chosen exercise you can be sure that injury will occur less frequently. This is especially true regarding stress fractures of the lower extremity!

        Your legs and feet are at the bottom of your body and they suffer the abuse of running and jumping associated with exercise first-hand. Repetitive motions and the subsequent impacts cause the parts of the bones that are absorbing the most shock to wear down or weaken. If you’ve ever changed up your exercise habits suddenly or increased the intensity of your runs you may have noticed your shins or feet began to hurt during exercise. These may be signs of a stress fracture, usually a small break in one of the metatarsals of the foot. 

(Picture of the foot from emoryhealthcare.org)

        If you think you might have a stress fracture, the best thing to do is to rest the foot! (Stop running.) There may be some light bruising, swelling or redness around the area that is hurting. Of course, elevating your affected limb and utilizing ice packs will help decrease pain and swelling!

        Depending on the severity of your stress fracture, you may need a special shoe or boot that takes the weight off of your fracture site. In worst-case scenarios, a cast and crutches will be what are required to get you back to 100 percent.

        In situations where bone is the healing tissue there are many factors that can affect the speed of recovery. Patients who are diabetic or smokers will find themselves with a stress fracture for significantly longer than their counterparts who do not have compromised vascularity. Proper nutrition that includes a lot of Calcium and adequate rest will ensure the right environment for bone healing. 

(Radiograph from newyorkfootexperts.com)

**** Runners that take a break for winter should use caution when returning to their exercise regimen and begin at a lower level to protect their bones! ****

        Exercise, however, is not always the culprit when a stress fracture is suspected. In patients with Osteoporosis or a general decreased bone density, fractures can occur from normal activity. (Walking, Standing or Using the stairs.)

        Women athletes, especially very slim ones, have been found to be at an increased risk for stress fractures due to hormonal imbalances and their subsequent disposition to Osteoporosis.   

     Whether you are very active or only take the occasional stroll, it is important to maintain a balance between the many factors related to bone and foot health.

           Be safe and keep those feet happy! 

        With all the activity happening in the world of sports, both domestically and abroad, there are bound to be an increasing number of injuries to tendons. Since your tendons connect your muscles to your bones they often take a significant amount of abuse and often show signs of wear and tear. Plantar fasciitis and even problems with the Achille’s Tendon are some issues involving your tendons that Podiatrists commonly diagnose and treat.

        When an injury occurs, the human body mounts a response to begin healing it immediately. In a case in which a tendon is torn, ruptured or strained, your platelets and other blood cells begin to work together to fix the damage.

        Although the platelets do cling together to form a platelet-plug and stop bleeding, they have been found to also secrete growth factors that promote wound healing and attract beneficial cells to the damaged area. 

      (Platelets in their active form in the blood. Picture from www.thrombosisadviser.com)

        Given the healing power of these tiny particles in our blood, doctors began performing Platelet-rich Plasma (PRP) injections in the late 1980’s to help patients in critical condition. The procedure is very simple and is explained below.

Step One: Blood is drawn from the patient. Not very much!

Step Two: The collected blood is placed in a centrifuge that concentrates the platelets and growth factors into a smaller amount of plasma.

Step Three: The Platelet-Rich Plasma is then carefully injected into the site around your injured tendon! 

(Picture from www.stemcellorthopedic.com)

After the injections, you may experience some discomfort, but do not despair! Your body is reacting in the normal and desired way to the sudden influx of platelets and healing factors. You may want to ice and elevate your injury, perhaps even use Tylenol for pain relief. But ibuprofen, Advil and other NSAIDs will produce the opposite reaction that the procedure is trying to create.  

This treatment should be just a part of a rehabilitation planned by your doctors in order to get you back to your best. Finally, the PRP injection process may seem to be over-simplified, but it really is a very easy and effective way to treat tendonitis in all its forms.

****PRP injections routinely speed up the rate of healing in tendon-related injuries and are ever-increasing in their popularity amongst Sports Medicine physicians!****

Another impressive use for PRP injections is in the field of wound care. Patients with chronic wounds, diabetic or otherwise, often find that their physicians struggle with treating these persistent wounds and the subsequent infections and other issues. The processes that help with the tendonitis are the same ones that assist in the closing and healing of chronic wounds. The growth factors abundant in PRP are the perfect assistant to the struggling wound bed!

Much like the PRP injections, blood is taken from the patient and centrifuged into its components. The difference is that in the case of chronic wounds there is an open area that is not closing. The PRP is combined with an enzyme present in your body that works as a blood-clotting factor. This newly formed PRP gel can then be applied to the pesky wound and begin the task of laying down new collagens for healthy skin to grow over and promote new vasculature to feed the healing wound. 

(Picture of a PRP gel being prepared from www.plateltex.com)

            Researchers are working around the clock to try to find new ways to heal the human body. From wound healing to cancer treatments, we as physicians are also working to facilitate the use of these new discoveries in the safest and most beneficial way possible for our patients. In the case of PRP treatments, it is the marriage of our human biology and physiology to the latest trends in medicine that allow us to provide excellent care to you and yours.

References:

(1)Sampson S, Gerhardt M, Mandelbaum B. Platelet rich plasma injection grafts for musculoskeletal injuries: a review. Curr Rev Musculoskelet Med. 2008 Dec;1(3-4):165-74.

(2)Smith R, Gassman C, Campbell M. Platelet Rich Plasma: Properties and Clinical Applications. The Journal of Lancaster General Hospital. Summer 2007. Vol 2. No 2. 73-78.

(3)Lacci K, Dardik A. Platelet-Rich Plasma: Support for Its Use in Wound Healing.  Yale Journal of Biology and Medicine 83 (2010), pp.1-9. 

                 Fungi have long held a very important role in the ecosystem and even in our recipes. Although they grow in the ground and appear to be plants they are actually eukaryotic organisms and either eat dead material or live as parasites on others. You may be shocked to hear that a relatively common malady is essentially just a fungus making your skin its home!

                Tinea Pedis, or more commonly known as Athlete’s Foot, is an itchy, red, flaky rash that grows in areas of our bodies that are mostly kept warm and moist. Our feet, armpits and groins are essentially the perfect breeding ground for these fungal infections.

**** Many of the fungi that cause these rashes are of the same family and often cause skin diseases in animals! ****

(Picture of Epidermophyton floccosum from Wikipedia. This fungus specifically prefers humans!)

                  The way in which most people acquire this infection is through contact of their skin with a surface that other infected people have come into contact with. Showers, saunas and even the areas around swimming pools have been found to harbor the spores of these pesky creatures. After these spores establish themselves on your skin they lay in wait for your socks, shoes and clothes to cover them and create the environment that they love.

                 Prevention is the best solution to this problem, but if you find yourself with Athlete’s Foot you have a few options to get rid of it.

-       Do nothing. In some cases, if you bathe and change your socks often enough, the natural antifungal properties of your skin will snub out the invading fungus.

-       Topical antifungals, in creams or sprays, will take care of the problem. They are found at most drug stores and supermarkets.

-       Using foot powders will help keep your feet dry inside of yours shoes and socks, therefore leading to less fungus!

-       Don’t forget to wash and/or disinfect your shoes. If it’s on your feet and your feet have been in your shoes…It’s in your shoes too.

-       In some of the worst cases of tinea pedis, bacterial infections can also appear in the areas irritated by the fungi. If you are noticing that your condition is worsening or has persisted for too long you should see a doctor! 

(Picture from kesq.com)

**** Wearing sandals or just plain going barefoot once in a while is healthy for your feet and will help prevent the dreaded foot fungus!****

            In addition to an unsightly rash or stinky scent these foot fungi can make their way under your nails and establish themselves there for the long haul. Discoloration, thickening, becoming gnarly and misshapen are all consequences of prolonged nail fungus infection on your toenails!

            So be sure to keep your feet clean and dry, wash those old shoes that you have probably never washed, and remember to wear some flip-flops the next time you brave the showers at the gym!

 

            

    Peripheral Artery Disease (PAD) is a health problem involving the arteries that lead away from the core of your body, towards the periphery. (Legs, Arms and Head.) As a person ages the inside of their arteries become narrower as plaque deposits there. Due to decreased amount of blood, the tissues that the arteries supply get less oxygen and nutrients. This can cause cramps in muscles and even poor healing of cuts and bruises. 

(Picture of PAD from http://www.nhlbi.nih.gov)

     The risk factors associated with this disease are diabetes, smoking, uncontrolled levels of cholesterol in your blood and high blood pressure. Together these problems are the perfect storm in which PAD may develop over time.

**** Even if an artery in your leg becomes completely blocked by plaque, the lower part of your leg may still be receiving blood from other arteries that take over its workload! This is called collateral circulation. ****

    One of the best ways to protect against PAD is to have your doctor monitor you for health problems that put you at risk and remove other risk factors within your control. With that being said, an Ankle-brachial Index (ABI) is a simple and painless test that your doctor can perform to diagnose PAD.

(Picture of an ABI being performed from http://www.svnabi.org)

            Your brachial blood pressure, taken from both arms, is measured against the blood pressure taken from arteries on the top of your foot and the back of your leg. These measurements are then used in a formula to determine if the disease is present, and if so, at what level. In addition to arterial tests, many machines used to calculate ABI also measure the venous return in a patient to evaluate them for venous insufficiency simultaneously.

            If you are diagnosed with PAD there are several treatment options depending on the severity of the disease. Medications for Blood Pressure, High Cholesterol, Unregulated Blood Sugar levels and medicine to prevent blood clots form forming may all be prescribed to help treat Peripheral Artery Disease. In the worst cases, where clots have completely occluded an artery, surgery may be deemed necessary to re-establish the blood flow.

            PAD screenings should be a valuable tool in assessing your vascular health, especially in the lower extremity. PAD testing is performed in the office and is covered by most insurance plans. It is a mandatory test for diabetics, those with a family history of PAD and other vascular disorders. Dr. Garibaldi and Dr. Harper both utilize these methods to provide the best care they can for you and your family.





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