Lois: We'll be talking about metatarsalgia, disorders of the forefoot, with Dr. Brett Fink. Dr. Brett Fink is an orthopedic surgeon at the Indian Orthopedic Center and author of the book, The Whole Foot Book
, a general reference on foot care which will be published in December of this year. I am Lois Wingerson. Welcome, Dr. Fink.
Dr. Fink: Thank you, Lois.
Lois: Dr. Fink, what are the biggest challenges in diagnosing and treating metatarsalgia?
Dr. Fink: Well, let's start by defining what metatarsalgia is. Metatarsalgia simply means forefoot pain. And so metatarsalgia by itself is a description rather than a diagnosis. And so the biggest challenge in diagnosing and managing this problem is really to make the correct diagnosis. Traditional medical training, the type of training that a medical student generally has, is not very complete in describing musculoskeletal problems. It's more something that people generally pick up as they go along during training. It's even more weak in foot and ankle problems, because for the most part these problems have been relegated to the podiatric community. A significant portion of the people saying a primary care doctor will have foot problems even though this may not be the primary complaint. The forefoot is not a very big structure, but it's packed with a lot of stuff, ligaments, tendons, arteries, bones, and nerves. And all of these things can be a part of the problem. Being familiar with the anatomy is very important in understanding what can go wrong with it. That is probably the biggest thing that a physician needs to know. You need to be aware of the diagnoses metatarsalgia is commonly caused by, because you can diagnose what you don't know. After this, many effective nonoperative treatments can be instituted even by the primary care physician. This is one of the reasons that I wrote The Whole Foot
, to help patients and their physicians learn about nonoperative care, because often it is passed over. People often go straight to an operation, which is really a unnecessary shame in my opinion.
Lois: What are the keys to determining the cause of metatarsalgia pain?
Dr. Fink: I think the key is a careful physical exam. And that involves really meticulously going over issues such as skin, nerves, and circulation as a part of the general exam and then being very careful to define exactly where it hurts. One diagnosis, Morton's neuroma, is really very over-diagnosed. The reason is because Morton's neuroma may be the only diagnosis that the physician may be familiar with that causes forefoot pain. If someone has pain which is really across the entire forefoot or is where Morton's neuroma pain is usually not present, then this is probably not the cause of the problem. Also, I think it's important to understand how deformities may interact with the causes of forefoot pain.
Lois: Please explain how other structures may be involved in the development of forefoot pain.
Dr. Fink: It is very important to understand that the foot does not exist in isolation. The simple act of walking is really a function of the back, the hip, knee, and the entire leg. And all the joints, ligaments, and muscles of each one of these areas are involved in the act of walking. Any dysfunction of any one of them will affect the way that the foot experiences pressure, and this pressure is what overloads the foot and causes many common foot problems including metatarsalgia. One of the results of this dysfunction is to shift the pressure in the foot from the entire foot and concentrated on the forefoot itself. This will eventually wear out a structure in the foot. If the weak part of the foot chain is the forefoot, then you will get metatarsalgia. One common illustration that I can think of off the top of my head is that all of someone that has a restriction of knee motion because of osteoarthritis or hamstring contractures, this will subtly change the way that they walk. It will shift the weight to the forefoot. This is something that we can look at on a forefoot pressure scan, a computerized device that measures the pressure on different parts of the foot as we step. Hamstring contractures, according to one article, were the factor most associated with common foot complaints.
Lois: Thank you very much, Dr. Fink.
Dr. Fink: Thank you very much, Lois. I've enjoyed it.
Forefoot pain is one of the most common problems that I see in my clinic. There is rarely a day that goes by that I do not see someone with pain and swelling in the front portion of the foot. When I speak of forefoot pain, I'm speaking of pain in the ball of the foot, excluding the big toe.
Usually this pain occurs without trauma or other accident. The most common history is swelling and discomfort that occurs at the base of the toe gradually. This may occur with or without deformity. It is usually worse with activity and with certain shoes.
While several things can cause this including stress fractures, Morton's neuroma, several usually benign tumors, the most common cause is injury to ligament that is found on the bottom of the joint at the base of the toe, the metatarsophalangeal joint. This condition is not familiar to most nonmedical patients, and is commonly not familiar to many physicians who do not regularly see patients with foot complaints.
The major ligaments of the metatarsophalangeal joint are located on the bottom and sides of the joint. It is these ligaments that determine the resting position of the joint. The ligaments can weaken and tear. These tears are usually caused by gradual wear due to age, overuse, the shape of the foot, and many other factors. On occasion, the tear can be suddenly caused from a “jamming” type of injury, but often the ligament is abnormal before this injury.
A hammertoe can develop after these ligament tears. The exact deformity that occurs depends upon the way in which the ligament is torn. A tear, which occurs on the outside portion of the ligament, will allow the toe to tilt toward the inside (figure 1). When the ligament tears in this way, the second toe commonly begins to overlap the big toe; this is called a “crossover” second toe and is often associated with a bunion deformity of the big toe. In the same way, a tear on the inside of the ligament will cause the toe to deviate toward the outside of the foot.
When the tear involves the central portion of the ligament, a typical hammertoe deformity develops. This type of deformity occurs at both the metatarsophalangeal joint at the ball of the foot and the proximal interphalangeal joint, the joint in the toe closest to the foot. This deformity often causes a painful prominence over this joint from the acute flexion.
Unfortunately, once these deformities have developed, there is little short of surgery that can be done to correct the deformity. Often however the pain associated with the deformity can resolve without correction of the deformity. There is also no proven way to prevent the deformity from occurring even while in its early stages.
Reasonable treatment of this problem involves various methods of reducing pressure at this joint. These include stretching exercises focusing on the Achilles and hamstring tendons, maintaining proper posture, using stiff soled or rocker soled shoes, and using orthotic pads to offload the painful joints. Injections of steroid or cortisone medication into the joint can be very helpful in the short run to help relieve pain, however its safety and effect on the natural resolution of this problem has not been established. Overall more than half of the people that developed this problem do not require surgery although many will be left with toe deformities that usually are minimally symptomatic.
Mike Buchanan: Thank you very much. And good morning everyone. Well you know most people take a tremendous fuss in their overall health. That's why orthopedic surgeon, Brett Fink, has written a book about the importance of maintaining proper foot care. The foot is an amazing complex organ that provides a variety of activities during a person's lifetime. Dr. Fink will reveal the foot problems that are often misunderstood by the very physicians that we turn to for help. Furthermore, foot problems can affect every aspect of a person's life from work to parenting. These problems can be avoided and even reversed. Dr. Brett Fink is the author of the book, The Whole Foot Book: A Complete Program For Taking Care of Those Feet. And he joins us this morning. Good morning, Doctor, and thank you for joining us this morning!
Dr. Fink: Good morning, Mike, and thank you for allowing me to be on your show.
Mike Buchanan: Always nice to have you on the show. What are some ways to find the best foot care possible?
Dr. Fink: Well, I think that one of the ways to find the best foot care possible is to buy a reasonable pair shoes. I think that, despite what a lot of people think, orthotics are not necessary for a lot of things. For specific foot problems, they can be very important. And then to find a foot doctor who is knowledgeable and can help you with any problems that come up.
Mike Buchanan: For a person that has a foot problem is it best for that person to go to a podiatrist as opposed to a family doctor?
Dr. Fink: I suppose it depends upon what you're looking for. Certainly most people have exposure to a family practitioner on a regular basis, and for fairly minor problems I think that a family practitioner can help them with a lot of those problems. Certainly for a problem that is more persistent, is causing more problems, may be causing swelling, or foot deformity, then seen either a podiatrist or an orthopedist that is knowledgeable in foot problems could get them a little farther than it could with seeing a family practitioner.
Mike Buchanan: I was thinking, Dr., you go to a shoe store, and there are literally hundreds and hundreds of shoes to choose from. Do we sometimes make a mistake by purchasing the wrong shoes for a specific lifestyle or activity that we have?
Dr. Fink: Well, I think , Mike, that's an interesting question. First of all, I think we should take a step back, and look at the way the foot has developed. I mean, before hundred years ago, people didn't wear shoes very often and therefore the foot has evolved to do a fairly good job throughout our lifetime of performing without pain for our lifespan. So often shoes are not necessary or not therapeutic for most healthy feet. I think it is important to find shoes that fit properly and that, if you have foot problems, specific foot problems, then you should look for shoes that are designed, then mechanically counteract those problems.
Mike Buchanan: What are some of the most common foot problems that you find associated with the foot?
Dr. Fink: Well, the most significant problem I think is plantar fasciitis, or heel pain, also known as heel Spurs. That probably accounts for 30% of the people that I see in my office. Ten percent of people will have this sometime throughout their life. And usually it goes away without much problem. After that, various forms of tendinitis. All of these occur because of the way that we use our feet over a long period of time. Again, shoes are part of the problem, because in Western society we have begun to wear shoes that are fairly constrictive. A lot of times the muscles do not develop properly or become deconditioned and I think that this makes us prone to develop problems like plantar fasciitis, like Achilles tendinitis, like hammer toe deformities. That's what I go through in my book, I have developed a program to counteract those problems through exercise, therapeutic shoe wear when necessary, and overall good foot health.
Mike Buchanan: What are some other foot problems that, you know, you come across in your practice?
Dr. Fink: Well, again, hammer toe deformities are perhaps one of the biggest problems. And they often begin as simple swellings in the front of the foot and a lot of times people don't know what they are. You know, unfortunately, a lot of times if you go to a primary care doctor, who may not be quite as sophisticated about the number of diagnoses that he knows well, he may misdiagnose this as a Morton’s neuroma, a stress fracture, or something like that. And usually these problems begin as swellings that eventually become foot deformities. A lot of times the pain will go away but the deformity will persist. Other problems that you might run into are bunions, and various types of arthritis of the midfoot or forefoot. Arch pains, flattening of the arch, there are hundreds of potential diagnoses.
Mike Buchanan: I'm sure you've seen, like I have, these commercials on television and they're usually in like a Walmart store, where you stand on this, kind of like a pad or something, and this machine will tell you that you need this specific type of shoe. Are these machines pretty reliable, accurate, what you think?
Dr. Fink: Well, I don't think that a healthy foot requires an orthotic. The foot that is having problems may require an orthotic and surprisingly there's not much of a difference between orthotics. Studies have even looked at custom orthotics versus the type that you get over-the-counter at one of those kiosks and there is only very subtle differences between them. And foremost normal feet, feet that don't have significant deformities but are painful, just a simple over-the-counter orthotic can help many problems. But those machines, unfortunately, only look at a very small part of the foot, and therefore, I think it's difficult for machine to tell you what to do for any foot problem. And again orthotics are only a very small part of foot treatment.
Mike Buchanan: And you know these machines, Doctor, they are stepped on by hundreds of people don't they malfunction after a while?
Dr. Fink: Well, again, you have to look at the type of information that these machines are trying to get from your foot and it is, it's very limited. And they more or less determine how you distribute the weight on the foot while you are standing. And that isn't necessarily the same as when you're walking or you're doing any of the millions of things that we do during the course of the day. And so those machines, I think they only look at a very limited part of the foot and I think it's difficult for that machine to even judge whether orthotics are the proper way to go as they frequently aren't.
Mike Buchanan: Well, Doctor, let me ask you, we only have a couple minutes to go, are feet sometimes misunderstood?
Dr. Fink: Well, I think that, I still after 19 years of being a doctor, there are many things that I don't understand about the foot. I think that after years of considering some of these foot problems, you do eventually get some insight as to what is going on in them. But I think that, yes, the foot has many, many bones and joints and they all interact with the leg, so it's a very complex situation. But, in a lot of ways, the principles behind them are very simple to understand, but very difficult to convey to the patient during the course of a fairly short office visit.
Mike Buchanan: Doctor, how can someone obtain a copy of your book, The Whole Foot Book?
Dr. Fink: It's available through Barnes & Noble and Amazon and I think it's very reasonably priced. Really for the price that you can go to a physical therapist for one visit, it's much less than the copayment for physical therapist for one visit. And I think that people can learn a great deal if they just take the time to look into this stuff on their own rather than just expecting a doctor or physical therapist to teach them all of these things that I think are very important for them to learn during the course of their foot problem.
Mike Buchanan: As far as surgery goes, use surgery only as a last resort?
Dr. Fink: For most common problems, I think, surgery is almost always a last resort. It's very simple for a doctor to prescribe surgery for problem. They don't have to get a lot of help from the patient. It's time-consuming for doctors to go through with the patient, nonoperative treatment. And I think that it's overlooked and often not paid the attention that it should be. And I think that a lot of times people get in trouble because of that.
Mike Buchanan: Doctor, we have run completely out of time, Thank you very much for joining us this morning on Good Morning Magazine.
•January 22, 2012 • |
Let’s assume that because you have come to this website that you are interested in foot problems. Maybe you have foot pain yourself or maybe you are looking for information for someone else. You must realize that different sources will vary in their portrayal of medical topics. It is up to you to use your own intelligence to decide whether the things that these sources say ring true to you.
The first type is the scientist. This is what you get when you open a textbook of medicine. The Mayo Clinics have a very nice website that interprets their information like this. The information will sound very dry and unfortunately the recommendations will be very non-specific and difficult to follow. This is because science offers us very few clear answers when it comes to the treatment of foot and ankle problems in specific circumstances. Scientific study can speak to the results of treatment within populations, but for individual conditions and all of the myriad of complications that arise, it says much less.
Here is the Mayo Clinic Treatment for plantar fasciitis (http://www.mayoclinic.com/health/plantar-fasciitis/DS00508/DSECTION=treatments-and-drugs):
- “Physical therapy. A physical therapist can instruct you in a series of exercises to stretch the plantar fascia and Achilles tendon and to strengthen lower leg muscles, which stabilize your ankle and heel. A therapist may also teach you to apply athletic taping to support the bottom of your foot.
- Night splints. Your physical therapist or doctor may recommend wearing a splint that stretches your calf and the arch of your foot while you sleep. This holds the plantar fascia and Achilles tendon in a lengthened position overnight and facilitates stretching.
- Orthotics. Your doctor may prescribe off-the-shelf or custom-fitted arch supports (orthotics) to help distribute pressure to your feet more evenly.”
When you read this, what are you left with—really, nothing. Overall, these websites may be useful for general information, but do not help with self treatment or give the reader a clear idea of where to go or what to do. The good news is that they will not lead you wrong. The bad news is that they often will not lead you anywhere.
Scientists are responsible for the great advancements of medicine, but, as doctors, they are not particularly effective. Many are unwilling to take the risks necessary to give the specific instructions required to institute a treatment plan.
The second are the zealots. They are usually on the crest of the latest medical fad. When approaching medical treatment, these sources begin with a premise–that their procedure, medicine or whatever is the answer to whatever is bothering you. The scientific information is spun so that their treatment is supported and all other information is ignored or discounted, sometimes with an angry religious fervor. Perhaps, they believe that one single way of treating things works for a wide assortment of problems. This is the case with Prolotherapy, and a number of other treatments. Don’t get me wrong. These treatments and techniques may be very useful. Before widespread usage of these techniques is recommended, some proof is necessary.
Here is an excerpt from the prolotherapy.com website (http://prolotherapy.com/prolodefine.htm):
“The treatment is useful for many different types of musculoskeletal pain, including arthritis, back pain, neck pain, fibromyalgia, sports injuries, unresolved whiplash injuries, carpal tunnel syndrome, chronic tendonitis, partially torn tendons, ligaments and cartilage, degenerated or herniated discs, TMJ and sciatica.
Prolotherapy uses a dextrose (sugar water) solution, which is injected into the ligament or tendon where it attaches to the bone. This causes a localized inflammation in these weak areas which then increases the blood supply and flow of nutrients and stimulates the tissue to repair itself.”
First, notice the claim. What doesn’t it work for? Second statement, this is full of many factual inaccuracies. Dextrose injection does not cause inflammation. For the most part, it diffuses into the tissue rapidly. Even if it did hang around a bit, increased levels of sugars like dextrose essentially simulates the diabetic state, which has been shown in past experience to be unhelpful in healing soft tissue (as anyone with diabetic foot problems can attest). The other claims such as “increases in blood supply” are unsubstantiated by any research. Prolotherapy may be helpful. No one knows because all the claims are anecdotal. This means that the therapy was tried, it worked on someone, but no one says whether it did or didn’t work on many others.
Some zealots sincerely believe in their product or procedure. Others may have a financial stake in whether the product sells or not. If a clinic or doctor offers only one form of treatment, run away!! No one treatment fits all problems or situations. Be especially suspicious if the treatment’s indications are very broad or the claims are too good to be true. My advice is to carefully assess any claims and do your homework on any form of treatment. If the evidence isn’t there, then weigh the claim and the risks and decide for yourself. Realize however that faith in an unproven medical treatment comes with substantial risk. Many times, the risk is the wasted money and mild pain, but there are some very real complications for unproven treatments.
People with an engineer-mentality make the best doctors. Engineering is applied science as is medicine. An engineer takes the science (all the facts) and uses it in the real world. Unfortunately, everything that an engineer does is not proven either, because the facts have not been completely established for every problem, every circumstance, every person, but an engineer considers all of the facts and tries to objectively come to the best solution for a real world problem. He weighs all treatment options and objectively decides which has the best risk/benefit ratio. In the best circumstance, an engineer has no stake in the outcome of his assessment and is willing to change his view on problems as new information arises. All of us come to the problems with which we are presented with some bias, however. Many times this means that the assessment will be subjective in some sense. Errors will happen, because the outcome has not been proven.
In the end, it is you, the patient, who makes the final decision. All of the sources to which you turn may inform you well or poorly, but you have to weigh them all and decide what is best for you.
–Brett Fink, MD. Co-author of The Whole Foot Book: A Comprehensive Guide to Taking Care of your Feet
Doctors get foot pain too
One of my biggest reasons for writing The Whole Foot Book was to share the experiences and answer the questions that my patients have had over the years during the course of treatment. It may surprise some readers, but many of the conditions I have discussed, I have had personally. There are many conditions that I have identified that cause me to have a high chance of getting these problems. I have had lifelong problems with controlling my weight; I am not overly flexible; People have remarked on the bouncy step that I had as a child/adolescent as a result of my tight Achilles tendon. My activity has varied widely during my life from extremely athletic to “couch potato”-ish. And now, at age 48, my ligaments, muscles, tendons, skin, and bones do not have the resiliency that they once had. All of these problems lead to overloading the front of my foot.
As a result, I have had Achilles tendon problems repeatedly. I have developed and recovered from plantar fasciitis/heel spurs in each of my feet and I have developed a hammertoe after irritation of the second toe joint in the ball of my right foot.
While some conditions may require surgery for the best result, in most, especially non-traumatic, problems, surgery is neither the fastest nor the best method of recuperation. And while the scars that remain after many conditions (such as a hammertoe), may be objectionable and make me prone to re-injury, in my opinion, it is preferable to the problems (stiffness, numbness, and scars) that follow surgery. In some instances, the deformities and occasional persistent pain may make surgical reconstruction the practical option, but you must understand that there are alternatives to surgery. My foot problems have never come to this point, but those of a minority of my patients have and surgery was the logical choice for them.
These alternatives include exercise therapy (either by yourself or with the assistance of a therapist), temporary or permanent limitations to activity, weight-loss, and therapeutic shoe wear, braces and orthotics/inserts. There are also pain-relieving methods that include massage, anti-inflammatory and other pain medications, and heat and cold application.
Which is right for you? Most of the time it is a matter of trial and error. Usually you should try several methods that will fit in with your life and then modify, and adapt your regimen until you figure out what works for you. Find a doctor that understands your preferred approach to treatment and has the patience to work with this. Communicate your goals to him and often the best course of treatment becomes clear.
As for me and my feet, I have a lot of better things to do than recover from surgery or to take the chance of becoming my doctor’s next surgical disaster (and all sugeon’s have them). All surgeries have a chance of failure and it may surprise you that for most foot surgeries that chance is somewhere between 5% and 30%. In a few, it may be as much as 50%. But my case of plantar fasciitis, Achilles tendinitis, or hammertoe may not be your case and surgery is sometimes necessary. My advice is to give non-operative treatment a chance and this involves patience, persistence, and thought on the part of both you and your doctor.
How to Care for a Cast
•August 2, 2011 •
Casts are used for many purposes in the orthopedic or podiatric clinic including various forms of tendonitis, sprains and other soft tissue injuries as well as fractures. Proper care of your cast is important for the successful treatment of your problem and for your safety.
While casts can be uncomfortable and the conditions that they treat can be painful, the cast itself should not be painful. If your pain increases or if the cast feels too tight, you should elevate the cast above the level of your heart. If this does not quickly alleviate the problem, contact your orthopedist or podiatrist’s office or the on-call physician immediately.
Itching is also quite common. Over-the-counter anti-histamines such as Benedryl (diphenhydramine) and non-drowsy anti-histamine, Claritin (loratadine) can help stop this. Never stick anything into the cast to scratch your skin, because it can damage your skin and cause potentially serious infections and wounds. The Cast Cooler (www.castcooler.com) is a suction device that uses a vacuum to suck air through the cast. It seems to improve itching and smell associated with cast wear.
Protect your cast when in the rain or in damp places. If the cast gets slightly damp, it can be dried with a blow dryer on low heat. If it gets wet, the cast should be changed because it can damage the skin.
If a cast rubs on your skin, wounds and blisters can occur. This should be immediately reported to your doctor. Any drainage from the cast not related to a surgical wound or ulcer should also be immediately reported to your doctor. These areas are most common at the ends of the cast, especially the top of the foot, the front of the shin, and around the inside or outside of the foot. They are easily and quickly treated with replacement of the cast and simple wound care if they are caught early.
Fiberglass cast surfaces can be abrasive. It is advisable to wrap the cast with an ace wrap at night to avoid damaging your sheets, other leg, or partner.
Smell can also be a common problem and can be helped by regular cast changes usually every three or four weeks. Avoiding heavy physical activity and exercising also will help. Do not pour powder down the cast as it can cake and damage the skin.
Showering/bathing with your cast
It is impossible to guarantee that your cast will remain completely dry during a shower or bath, but most people are unwilling to forgo showering or take a “sponge-bath” for the entire time that they will be wearing a cast. While showering, avoid directing the showerhead at the cast or leg. Never submerge the cast no matter how well it is protected.
Ideally, you should wet your body for a short period. Turn the shower off and soap and lather appropriately. Turn the shower back on for rinsing. This minimizes the chance of moistening the cast. An excellent way of controlling the water is to use a spray attachment to the faucet. These are available at most hardware and discount stores for $10-15.
Prepare the cast by taking a washcloth or hand towel and rolling or fold it into a tube. Tape or ace wrap this above the cast. Place the cast and towel completely within a heavy plastic bag and secure with a rubber band. If there are significant circulatory problems, then the rubber band should be very loose. If the cast is a lower extremity cast, then an ace wrap should be wrapped around the weight-bearing portion of the cast to avoid abrasion and tearing of the plastic bag by the cast.
Commercially-available cast protectors can be substituted for the plastic bag and can be obtained at most medical supply stores or online. The cost is about $30. Manypeople find them more convenient than plastic bags, but they also can leak. Placing the hand towel above the cast and below the cast protector is still advisable. The Drypro cast protector is slightly more expensive, but is the only cast protector on the market that I would feel secure enough with to skip the above preparation.
-Brett Fink, MD, Indiana Orthopedic Center, Indianapolis, IN, (317) 588-2663
•August 6, 2011 •
Although it has been around for over 15 years and has been used with some success in treating difficult-to-heal wounds, platelet-rich plasma (PRP) has come into the literature recently for the treatment of many musculoskeletal conditions including tennis elbow, patellar and Achilles tendonitis. In addition, the successful use of PRP in the treatment of the injuries of many sports figures has been widely publicized. Some physicians that treat these problems are beginning to offer these treatments to their patients, sometimes as a last resort before surgery, sometimes, unfortunately, as an initial treatment. Most insurances have not yet begun to cover this treatment, citing its experimental nature. It can be very expensive to pay for out-of-pocket ($500-1000 or more).
Platelet-rich plasma is a preparation created from blood. The blood is taken from a vein and spun by a centrifuge. This separates the blood into blood cells, serum, and platelet-rich plasma. Platelet-rich plasma, as suggested by the name, contains a lot of platelets. These small fragments of cells when activated release a soup of proteins called growth factors that start the clotting and healing cascade after an injury. The preparation is then injected into the irritated area. Are they the right proteins to help a painful heel heal? Nobody knows.
According to Orthopedics Today, a widely distributed periodical for orthopedic surgeons, a study looking at the effect of PRP on plantar fasciitis was recently presented by Dr Raymond Monto at 12th EFORT Congress in Copenhagen in June 2011. In it, he found that the 40 patients that he studied did significantly better with the PRP injection than the cortisone injection. Dr. Monto is also a speaker for Exactech, a company that markets devices for the production of PRP.
Plantar fasciitis is a sometimes excruciatingly painful and frustrating irritation of the heel. It is the most common cause of heel pain and seems to be the result of chronic scarring of the plantar fascia, an important ligament that connects the heel to the toes and supports the arch. Plantar fasciitis commonly resolves on its own. More than eighty percent of people with plantar fasciitis get better within 6-12 months, sometimes without any treatment. Unfortunately, a portion of them do not. They can be a very unhappy group.
Over the last two decades, many treatments have come in and out of fashion for plantar fasciitis. In the early nineties, night splints, plastic splints that you strap on at night, were the solution. Subsequently, further scrutiny showed the results to be inconsistent and usually fairly marginal. In the early 2000s, Orthotripsy, the application of a high strength shock wave machine to the heel, promised to be the answer. Many orthopedists and podiatrists bought these machines. The manufacturer of one, the Ossatron, has since settled a class action suit over misrepresenting the results of this treatment. Coblation, the use of a probe to burn small holes into the plantar fascia, came out about the same time. Although I have heard little to state that it isn’t effective, the only paper on it over the ensuing years studied 14 patients. It was overall positive, but the evidence is still not sufficient to recommend it to my patients. No published literature is available from a center inside the US. Botulinum toxin, a chemical that paralyzes muscle for months where it is injected, best known for cosmetic treatments of the face, has been suggested beginning in 2005, but the studies to date involve less than thirty patients.
According to a systematic review of blood products including PRP by Van Vos et al in the British Medical Bulletin (2010):
“All studies showed that injections of autologous growth factors (whole blood and PRP) in patients with chronic tendinopathy had a significant impact on improving pain and/or function over time. However, only three studies using autologous whole blood had a high methodological quality assessment, and none of them showed any benefit of an autologous growth factor injection when compared with a control group. At present, there is strong evidence that the use of injections with autologous whole blood should not be recommended. There were no high-quality studies found on PRP treatment.”
Many PRP systems come with the FDA required warning, “The platelet rich plasma prepared by this device has not been evaluated for any clinical indications.” In other words, the evidence to recommend PRP for anything is just not there yet.
While PRP is a promising treatment and evidence may eventually justify its cost, it should not be used as anything short of a last resort prior to surgery. Considerable out of pocket expense should be anticipated. It is my opinion that it should not be used outside of clinical trials until further evidence demonstrates clearly its effectiveness.
-Brett Fink, MD, Indiana Orthopedic Center, Indianapolis, IN, (317) 588-2663, co-author of The Whole Foot Book, A Complete Program for Taking Care of Your Feet.
What You Need to Know about Narcotics
•August 12, 2011 •
Narcotic analgesics (medications that treat pain) are commonly used to treat pain after surgical and traumatic injuries. They work by mimicking endorphins that help with pain naturally in the body. However, there are many things that you should know about this class of medications.
Normal side effects of these medications include nausea and vomiting, itching, sleepiness, wakefulness, vivid or bizarre dreams, and constipation. Sometimes these side effects are tolerable. Occasionally, they require treatment with other medications. Often, the medication must be stopped or changed because of the side effects. Nausea can often be treated by medications such as phenergan that can be taken by mouth, rectally using a suppository, or by injection at a medical facility. Itching can be sometimes controlled through the use of over-the-counter antihistamines such as Benadyl, Zyrtec, or Claritin. Constipation nearly always occurs to some degree and can be lessened by ensuring that you drink plenty of water. Over-the-counter laxatives such as Metamucil or Colace should be started at the first indication of problems. Your doctor if necessary can prescribe stronger laxatives. True allergic reactions are rare.
All narcotics carry with them a risk of dependence or addiction if taken for a long time. Withdrawal symptoms such as agitation, nervousness and tremors sometimes are felt after discontinuation of narcotics. Some forms of discomfort do not seem to respond very well to narcotics regardless of the dosage and should be managed using other methods.
Narcotic analgesics are controlled substances and it is against the law to alter or forge prescriptions for narcotics or to give them to anyone else but the person for whom they were prescribed. No person should receive narcotic prescriptions from more than one doctor at a time.
If it is discovered that you are obtaining narcotics from more than one doctor, you will be denied further narcotic prescriptions from this office.
Most narcotics that are prescribed for moderate pain last about four to six hours. Some newer long-acting narcotics last longer, but also take longer to get into your system. If pain medication is necessary on a round-the-clock basis, these narcotic preparations may be prescribed according to your doctor’s recommendations.
Narcotics are effective medications for the relief of pain. However, they should not be used longer than they are required and are not a particularly effective way of managing pain over a long term.
-Brett Fink, MD, Indiana Orthopedic Center, Indianapolis, IN, (317) 588-2663, co-author of The Whole Foot Book, A Complete Program for Taking Care of Your Feet.
•August 12, 2011 •
Bone density loss is a normal part of aging. Density is basically the amount of bone that is in your bone. The spongy struts that make up the bone tissue at the end of the bones near the joints thin, making them more fragile. It begins at the age of about thirty and continues at a low rate until menopause, but it accelerates for a few years after menopause. Bone density loss is not usually painful and is not associated with arthritis, but, if it becomes excessive, it can predispose you to painful fractures commonly in the hip or back, but also in the wrist, ankle, shoulder, and knees. It is also treatable and preventable.
Bone density can be measured using a test called a DEXA scan. DEXA stands for dual emission x-ray absortimetry. Essentially a special x-ray is taken that allows doctors to measure the amount of the x-rays that is absorbed by the bone. This relates to the density of the bone. The test is painless, quick, and covered by Medicare and most insurances. It can be scheduled at the hospital by our office. It measures the density of the bone using a T- or Z-score, which compares your bone density with that of 20 year-old females (T-score) or people your age (Z-score). A score of -2.0 means that you have less bone density than 90% of people.
Treatment of mild bone density loss involves proper nutrition. Adult should get at least 1200 mg of calcium daily through diet and supplementation. They should also get at least 1000 IU of Vitamin D daily. While taking less than this can accelerate bone loss, taking more than this will not increase it and excess intake (several times the recommended amount) can lead to health problems.
People with a T-score of less than -2.5 or less than -1.5 with additional risk factors should be treated with medication. There are several medications that are FDA approved for osteoporosis. These are listed below.
Miacalcin nasal spray (calcitonin) 200 IU administered as a nasal spray daily
Problems: Nasal irritation
Evista (raloxifene) 60 mg tablet daily
Problems: Possible increases in risk of blood clots, heart attack and stroke. Hot flashes and leg cramps are the most common side effects.
Fosamax (alendronate) 700 mg tablet weekly
Actonel (risedronate) 5 mg daily, 35mg weekly, or150mg monthly
Boniva (ibandronate) 150 mg monthly
Reclast (zoledronic acid) 5 mg given intravenously yearly
Problems: Should be taken on an empty stomach, Irritation of the esophagus/heartburn, osteonecrosis of the jaw, musculoskeletal pain, do not use with kidney failure, hypocalcaemia.
Forteo (teriparitide) 20 mcg injected daily for no longer than 2 years.
Problems: Possible increase in bone cancer (evidence in rats only), avoid with Paget’s disease, hyperparathyroidism, and hypercalcemia, hypotension.
-Brett Fink, MD, Indiana Orthopedic Center, Indianapolis, IN, (317) 588-2663, co-author of The Whole Foot Book, A Complete Program for Taking Care of Your Feet.
Diabetes and the Foot
•August 12, 2011 •
People who have diabetes mellitus should be very concerned about their feet. The most common complications of diabetes are from damage to the eyes, kidney and the feet. Almost everyone knows someone who has had a disastrous complication of the foot because of diabetes. While diabetes is the most common disease resulting in amputation, amputation is actually fairly rare when considering the number of people with diabetes. Careful foot care, aggressive treatment of blood sugar levels, and smoking cessation will usually help prevent this.
The increased sugar concentration in the blood of people with diabetes damages nerves. The longest nerves are damaged first and these happen to be the ones to the foot. The result is numbness, changes in circulation, muscle weakness, skin rashes and stiffness of the toes.
There are two reasons that the nerves are damaged. First, glucose can actually attach to the all proteins in the body including those that are in nerves. Most proteins in the body have a limited lifespan. They are continually produced and broken down. The proteins that do not turn over rapidly or are made of certain reactive amino acids can have enough glucose attached to them to impair their function. Proteins in the nerve membranes that control the electrical impulses of the nerves seem to be prone to this damage. Second, the increased glucose concentration promotes the production of certain toxins within the nerve cells that hamper their ability to generate energy.
Diabetes can also accelerate hardening of the arteries or arteriosclerosis. This causes the arterial circulation of the foot to decrease, eventually starving the foot of food and oxygen. When the loss of circulation is combined with the numbness, the foot becomes prone to injury and these injuries are much more difficult to coax into healing. Problems that occur in people with diabetes include painful neuropathy, stress injuries, ulceration, and infection.
Painful neuropathy or pain from the sick nerves is generally perceived as burning, aching, or a tight feeling in the feet. It is often more intense at night and can be severe enough to require medication. Initially, anti-inflammatory medications such as naproxen (Aleve) and ibuprofen (Advil, Motrin) and other over-the-counter pain medications such as acetaminophen (Tylenol) can help these symptoms. Lotions such as capsaicin (Zostrix) can also be applied and give relief. When beginning treatment with this lotion, burning is often noted, but generally resolves with the first few days of application. Other prescription medication such as gabapentin (Neurontin), duloxetine (Cymbalta), pregabalin (Lyrica) and topiramate (Topamax) are also effective in more severe cases, but have more side effects. Perhaps the most effective method of addressing these symptoms is careful control of the diabetes through effective medication and monitoring serum glucose level at home with the help of your primary care physician.
Stress injuries, otherwise known as diabetic arthropathy or Charcot arthropathy, are sometimes sustained by people with diabetic nerve damage. The initial symptoms are unusual swelling, redness, and pain. It is often confused with infection. A simple “sprain” is not simple in someone with diabetes. If you experience any of these symptoms, an orthopedist, podiatrist, or other physician should evaluate you immediately. This injury can lead to foot deformities so severe that they require surgery, because the deformity may make wearing normal shoes impossible without injuring the foot. The treatment is protection, immobilization, and/or prolonged restriction of weight bearing using cast, crutches or a walker for as long as six months. Surgery is occasionally necessary.
Ulceration is caused by repetitive or prolonged pressure on a portion of the skin. The pressure can impair the circulation until it the skin dies. Often pressure from a bone underneath the skin combined with age-related thinning of the protective skin causes it, but prolonged pressure to the back of the heel can also cause pressure this great just by resting the foot on a hard surface. A person with diabetic nerve damage should never elevate their leg on a table or other hard surface for a prolonged period of time or use heating pads on their feet. The break in the skin can lead to infection of the deep structures if left untreated. Early signs of a possible ulceration are a heavy callus, blue, black or purple patch (caused by bleeding underneath the skin), or a blister. If you have an ulceration or any of these other warning signs, you should be under a doctor’s supervision until the ulcer is completely healed.
-Brett Fink, MD, Indiana Orthopedic Center, Indianapolis, IN, (317) 588-2663, co-author of The Whole Foot Book, A Complete Program for Taking Care of Your Feet.
•August 16, 2011 •
The decision to undergo surgery can be associated with many feelings. While you may be excited to be on the road to recovery, the unfamiliarity that most of us have with surgery can instill much fear: fear of the anesthetic, postoperative discomfort, and potential complications. It would be unusual if you did not feel this. This document should answer many of the questions that you may have about your surgery.
Prior to the surgery, you must discontinue most blood thinners. For aspirin and plavix, this should be six days prior to surgery. For coumadin, it should be three to four days. For other anti-inflammatories such as ibuprofen (Motrin/Advil), and naproxen (Naprosyn, Aleve), it should be one day. Other analgesics such as acetominophen (Tylenol) and celecoxib (Celebrex) can be taken right up to the time of your surgery.
For general anesthesia, you must be without food and water for at least six hours. Medications can be taken with sip of water. For most surgeries, this means that you cannot eat anything after midnight the night prior to your surgery. Please report any scratches or wound around the operative site to your surgeon as soon as possible. Tell your anesthesiologist and nurse about any changes in your medical condition or new cold, flu or other respiratory problems. Ensure that your doctor and anesthesiologist is aware of all of your medications including diet pill and herbal and nutritional supplements.
Many surgeries are under general anesthesia (going to sleep). Most patients feel more emotionally comfortable this way. However, many surgeries can be under a local anesthetic or spinal. If you are interested in this, bring it up to your surgeon or anesthesiologist who will let you know if it is possible and compare the risks of this to general anesthesia. During the operation, often local anesthetic is used. Do not be alarmed therefore if there are patches of numbness around the operative area.
Often narcotic pain medications are necessary to help with the pain. These medications help to decrease pain, but most people continue to be aware that they are experiencing pain. Narcotic pain medications can make you nauseous, constipated, and itchy as well as make you feel funny and, occasionally, give you strange dreams and make you disoriented. These problems to some extent are to be expected and are not really allergies. Some can be avoided by changing the narcotic, lessening the dosage or by giving other medications to treat these symptoms. Most narcotic preparations contain acetominophen (Tylenol) and so taking additional Tylenol should be avoided, but you can sometimes take other over-the-counter analgesics such as Motrin and Aleve while taking narcotics. However, if you have undergone a procedure where bone healing is necessary such as fracture fixation, osteotomies, fusions, and joint replacement, it is currently recommended that these medications should also be avoided.
You may notice some changes for some time after the procedure. The leg or arm may become purple, blue or red when it is allowed to be dependent (hanging down such as when you are sitting). This is common and is caused by sluggish emptying of the veins when the leg is swollen. Swelling is often prolonged. Even in minor surgery, some degree of swelling is common for months. In major reconstructions, swelling can last for six months or more. It is lessened by limb elevation. Ice is not especially effective. Compression stockings can be used to control it, but are only effective while they are being worn and some find the tight stocking to be uncomfortable or difficult to put on.
•August 18, 2011 •
After any operation or injury, there will be a certain amount of postoperative pain. It is the responsibility of you and your surgeon to minimize this. There are several ways of doing this.
Non-steroidal anti-inflammatory medications such as Motrin, Naprosyn, and Celebrex and other over the counter analgesics such as Tylenol are the first line of pain control. These are often helpful additional medications and, later, during the recovery can be the primary method of pain control. Until confirmed healing of bone cuts (osteotomies), fusion (arthrodesis), or fractures is made, Non-steroidal anti-inflammatory medications should be avoided. Narcotic medications such as Vicodin and Percocet are a mainstay of postoperative pain management. These medications have several problematic side effects such as nausea, itching, constipation, drowsiness, addiction, and mood changes. Minimizing the amount of these medications is in your best interest. Make your doctor aware of any problems that you have had in the past with these medications. As many as 50% of people have some degree of nausea with certain narcotic pain medications.
Other medications are increasingly being used that were originally developed to treat seizures or depression. These medications include gabapentin (Neurontin), pregabalin (Lyrica), fluoxetine (Cymbalta) and many more. The side-effects of these medications are considerable including mood swing, drowsiness, and nausea, as well as many more. Probably the most worrisome are thoughts of suicide. If you experience this, you need to contact your doctor immediately.
Regional anesthesia or numbing the surgical area is an increasingly common method of pain management. Local injection of anesthetics like Lidocaine and Marcaine will numb a nerve and the area of the body to which the nerve gives sensation will last for two hours and sometimes more. This can be used as the only method of anesthesia in some types of surgery. Placing a catheter along a major nerve can increase the length of time that this anesthesia lasts. Rare complications of this form of anesthesia include irritation of the nerve.
Potentially the most effective method of controlling pain is decreasing worry and stress. Worry about your operation or injury—will it heal right, are the sensations that I am feeling normal, what about the lawn, housecleaning, what about my job and finances—is very common, but counter productive. You may have a lot of time on your hands to stew over these things. Try to relax. Find things that you enjoy and occupy yourself with them. Take care of the things you can, follow your doctor’s instructions, and realize that there are many thing that you cannot do or change.
Here is a list of things that you could do:
- Video Games
- Read a good book
- Organize your photo or digital photo album
- Do puzzles
- Research a topic that you have always found fascinating
- Write letters
- Learn a craft
- Read the newspaper
- Think of other things that interest you!!
Increasingly, plans for postoperative pain management are multidirectional. This allows you to begin recovery more comfortably and, ultimately, more completely. Discussion with your anesthesiologist and surgeon can help make your recovery as pain-free as possible. Recovery is not only a physical journey, it is also a mental journey.
-Brett Fink, MD, Indiana Orthopedic Center, Indianapolis, IN, (317) 588-2663, co-author of The Whole Foot Book, A Complete Program for Taking Care of Your Feet.
•August 21, 2011 •
Why Do Wounds and Ulcers Form?
Wounds are common problems that we all experience many times throughout our life from childhood to old age. Our bodies have developed the ability to very efficiently and effectively heal them, usually with very little medical attention. An ulcer is a wound that has not healed in a normal period of time. It can be distressing coping with this for reasons that hardly need to be mentioned. There are a few things that you should understand about your wound and its treatment to decrease the time it takes to heal it, and to minimize the chance that it will recur.
Diabetes is the most common cause of foot ulceration. The increased blood sugar in people with diabetes is toxic to nerves. The longest nerves are affected earliest and so nerve damage occurs first in the feet. The loss of sensation can make it difficult to protect the feet from trauma. In addition, the loss of sensation can increase the chance of developing fractures that can become severe and deform the foot and ankle. The nerve damage can also affect the nerves to the muscles in the foot causing stiffness and deformities such as hammertoes. All of these changes, the loss of sensation and the changes in the distribution of pressure on the foot as a result of the foot deformities, can lead to poor and prolonged wound healing.
Arteriosclerosis or hardening of the arteries does not affect only the arteries in your heart. It can also affect the arteries in your legs. Diabetes, high blood cholesterol and fat, high blood pressure and smoking can start and accelerate this process. When the arteries in your legs become damaged by arteriosclerosis, the flow of blood is decreased. This keeps oxygen and energy from getting to your tissue and decreases the ability of your tissue to regenerate. Caffeine can constrict them further and so large amounts of coffee or other caffeinated beverages can also hamper circulation as well as increasing blood pressure.
Varicose veins and the rashes that form from damaged veins can cause edema and make the skin fragile. If you have a brownish or reddish discoloration above your ankles in your calf area that does not go away when you elevate the leg, then you may have venous stasis dermatitis. In this condition, pressure in the veins is increased from poor emptying or previous blood clots. This causes the blood to leak into the tissues, resulting in scaring, discoloration, and fragile skin. Healing in this type of skin can be prolonged and troublesome.
Smoking can affect tissue healing in two ways. First, the smoke that you inhale contains carbon monoxide, the same gas that makes car exhaust so deadly. Carbon monoxide displaces the oxygen from the red blood cells, decreasing their ability to carry oxygen dramatically. Second, the nicotine in the smoke is a potent constrictor of blood flow in the tissues. Smoking and other forms of tobacco use have been shown in many studies to hamper healing of bones and skin.
What You Can Do to Help Yourself Heal?
Proper wound care is perhaps the most important step toward complete healing of a wound. A healing wound should be kept moist at all times. Skin cells must migrate from the edge of the wound and form new skin over the old wound. Dryness or desiccation damages these immature cells. In certain wounds, special dressings or ointments can help maintain this moist environment. Dressings should be changed at least every day to remove any fluid that comes from the wound and possibly more depending on the amount of soilage. Objectionable smell is due to the presence of dead tissue, loose skin, or secretions decomposing and usually means that additional cleaning or more frequent dressing changes are necessary. Increases in drainage or changes in the appearance or depth of the wound should be reported immediately to your doctor. Occasionally, surgical removal of infected or dead tissue is needed to begin the healing process.
Never clean your wound with anything that has not been approved by your doctor. Common home treatments such as soaking or rinsing in hydrogen peroxide, Mercurochrome, or bleach can actually harm healing tissues more than the bacteria colonizing the wound. However, the wound can be gently cleaned by a dilute unscented soap solution or clean soapy washcloth in a shower. A shower chair can be obtained to make showering considerably safer and prevent weight bearing on the wound.
Edema or swelling of the leg can hamper wound healing. While some swelling is unavoidable, excessive swelling impairs circulation. Your leg should be elevated four times a day for thirty minutes to help relieve this and should be propped up when sitting or lying down. Do not ice the leg to decrease swelling. The extremity should be kept warm to improve the circulation of the leg and speed the metabolism of the tissue, but never use heating pads or immerse the extremity in hot water.
Concentrations of pressure on certain parts of the foot are the most common cause of a wound formation on the bottom of the foot. Relieving this pressure is important in its treatment. The most effective way of relieving pressure is by eliminating weight bearing on the leg, using crutches or a walker. Unfortunately, because of problems with strength, endurance, and balance, many people cannot absolutely avoid weight bearing on one of their legs. If partial weight bearing is possible with a walker, then this is preferable to unprotected full weight bearing. Pressure relief shoes, pads, or casts can also help. It is important to avoid prolonged weight bearing, such as during long trips to the supermarket. Wheelchairs or electric scooters should be used if available. In some instances, surgical removal of bone or realignment of the foot may be necessary to alleviate bony prominences on the bottom of the foot before wounds will heal. This is rarely the initial form of treatment.
Antibiotics are sometimes prescribed for foot ulcers when they are infected. In my opinion, they are often overused and may be responsible for an increase in drug resistant bacteria. You must remember that ulcers take weeks or months to heal and long-term antibiotics for uninfected ulcers do not often shorten healing time and can possibly have negative effects. Oral antibiotics attack bacteria, not only in the wound, but also throughout your body. Many bacteria, such as those that are naturally in your intestine, are actually beneficial. Destroying these natural bacteria can lead to overgrowth of harmful bacteria that can cause diarrhea, nausea, skin rashes, mouth sores, and, in women, vaginal yeast infections. Topical anti-microbial medications are sometimes incorporated in ointments and dressings to reduce the quantity of bacteria on a wound.
Many bad habits can delay wound healing. Smoking is perhaps the worst. As mentioned above, nutrition of your wound is hurt in many different ways by the chemicals in tobacco smoke. While any reduction in smoking can help, quitting is the best way to promote healthy wound healing. Cutting down on sweets and alcohol is also helpful. These foods replace nutritious food and lead to reductions in vitamin and protein in your diet. Finally, drinking large quantities of caffeinated beverages can affect wounds and should be limited to no more than two cups of coffee or two soft drinks per day.
Nutrition is more critical during wound healing than ever. Protein requirements increase by 50-100% during wound healing depending on the size of the wound. Eating 1.5-1.7 gm/kg of body weight/d of protein can optimize your healing potential. For a 160-pound person, this is 100-120 grams of protein per day. Good sources of protein include lean meat, eggs, dairy, beans, peas and nuts. Below is a table giving rough estimates of the protein content of the most common food groups per serving.
Other vitamins and nutrients play a critical role in wound healing. Vitamin C is important in collagen formation, a key protein formed by your body during wound healing. About 500 IU per day is required in someone with a chronic wound. This is more than is in the typical multivitamin and if your diet is low in such things as raw leafy green vegetables, fruits, and potatoes. Boiling or steaming food leaches the vitamin into the cooking water, decreasing the foods vitamin content. The body does store this and so daily ingestion is necessary to maintain an adequate supply.
Zinc is a component of many of the proteins necessary to repair wounds. Zinc deficiency can lead to delayed wound healing. Zinc is found in most meat. In addition, beans, and nuts are sources of zinc. An adequate dietary intake is necessary to maximize wound healing potential, but it is not necessary to take more than the recommended daily requirement. A multivitamin with a vitamin C supplement is advisable if your diet is deficient in these nutrients. Maintaining adequate hydration is also very important to circulation.
Proper control of other medical problems can promote healing of ulcers. Perhaps central to this is proper control of diabetes mellitus. Tight control of blood sugar can reverse a portion of the nerve damage that diabetes causes. It can also promote a healthy immune system, because white blood cells work better when blood sugars are as close to normal as possible. Optimal function of the heart and circulatory improves blood flow to ulcers and decreases swelling. When peripheral arteriosclerosis impairs blood circulation, surgical correction through arterial bypass or stenting may be necessary.
Successful treatment of wounds and ulcers is a partnership between you and your doctor. Although wound care is very important to the healing of your wound, taking care of the rest of your health is nearly as crucial. Look to improve your diet and take the medicines prescribed for all your health problems to get your wound healed as quickly as possible.
•August 24, 2011 •
NSAIDs are a class of medication that primarily control the body’s injury response. Chemicals called Prostaglandins are released from many cells in the body and have a variety of functions. Some prostaglandins affect the production of protective mucus within the lining of the stomach. Other prostaglandins help regulate the uterus during the delivery of a baby. Still others help regulate the body’s temperature when we are sick and cause fever. The prostaglandins targeted with NSAID usage generally are involved in pain and inflammation. Two enzymes, proteins that chemically change chemicals within the body, are affected by NSAIDs and are called cyclooxygenase 1 and 2 (COX-1 and COX-2). The COX-2 enzyme is the one primarily responsible for pain and inflammation. Some anti-inflammatories selectively attach to the COX-2 enzyme and are called COX-2 selective.
Common anti-inflammatories are listed below with their trade names. They are generally prescribed for the treatment of pain. They do not typically decrease swelling, redness, bruising or effusion (water in joints). In fact, they can worsen these problems. They do not help common painful injuries and degenerative conditions such as arthritis heal, but they can make tolerating them easier. There is also some evidence that NSAIDs may slow bone healing, although studies in humans have not yet definitely proven this to be significant. It should be used only with caution in persons recuperating from joint fusion surgery, joint replacement surgery with prostheses requiring ingrowth (cementless joint replacements) and with fractures that are slow healing.
There are several potential side effects of anti-inflammatory medications. Because many NSAIDs attach to both COX enzymes, the medications affect the stomach causing indigestion and possibly stomach ulcers. They affect the platelets decreasing their ability to clot, “thinning the blood”. Other side effects include leg swelling, nausea, and diarrhea. Both nive NSAIDs such as Motrin and Aleve and selective NSAIDs such as Vioxx, Bextra (both off the market), and Celebrex (at higher medication dosages) have been shown to increase the risk of cardiovascular problems such as heart attacks. Persons taking the medication should consider carefully whether they are ready to take this risk prior to using the medication. Some medications have been taken off the market for this reason.
Acetaminophen is an analgesic (pain-relieving) medication that is not considered an NSAID, but is as effective as NSAIDs in reducing pain in medical studies. It is generally thought of as being safer overall than NSAIDs, but also has significant side effects. The most serious of these is liver toxicity. This is uncommon in doses less than 3 gm per day (6 extra-strength Tylenol tablets). Acetaminophen is also commonly added to other pain medications such as migraine preparations, cold medication, narcotics and Tramadol, so be careful that you are not already taking it in another medication.
None of these medications should be continued unless they decrease pain significantly. The best one for you is the one that works the best without intolerable side effects. If you have had a history of stomach ulcers, Acetaminophen or a COX-2 selective medication should be considered. However, some insurance plans will not approve the more expensive NSAIDs except under specific circumstances. The best advice is to try a couple before giving up on the pain relieving effect of this class of medications.
Common Anti-inflammatory Medications
Generic/Chemical Name Trade Names Cost
Aspirin Bayer Low
Ibuprofen Motrin, Advil Low
Naprosyn Aleve Low
Diclofenac Voltaren Mid
Etodolac Lodine High
Indomethacin Indocin Low
Nabumetone Relafen Mid
Sulindac Clinoril Mid
Peroxicam Feldene Mid
COX-2 Selective Prescription
Celecoxib Celebrex High
•August 27, 2011 •
Due to diabetes, peripheral vascular disease and trauma, the tragedy of limb amputation unfortunately continues to occur too frequently. The fact that complications are common after amputation only adds to the despair and emotional stress of the procedure. Phantom limb sensations are nearly universal after amputation. In its most innocuous form, the person with the amputation is merely aware that the limb is still there and at times can even sense movement of the limb. In approximately 50% of lower limb amputations, this sensation is painful sometimes terribly so. It can occur up to one year after the amputation and can be excruciating. It is confusing to understand how something that is no longer present can be painful and much about this phenomena is poorly understood, but some points can lead us to a general understanding about pain in other conditions.
Pain is a complex sensation that is processed and experienced at many levels within the brain. Our physical body is closely associated with a conceptual body within our consciousness and represented within our brain. There is a portion of our brains that is intimately associated with sensations including pain. In this portion of the brain, a specific area represents each part of our body. Certain parts of the body that are particularly important for sensation like our hands and our faces are over-represented. When an amputation occurs, the part of the brain that is devoted to sensing that portion of the body no longer receives normal sensory input. The sensory system then undergoes reorganization; adjacent portions of the cortex involved in the sensation of other parts of the body migrate into this neglected area and the portions representing the amputated part can shift. The amount of reorganization is correlated with the degree of pain. Certain therapies that help with phantom limb pain are actually correlated with a normalization of these brain changes.
Similar changes have been cited in reflex sympathetic dystrophy above and may also be involved in a number of other painful conditions such as painful diabetic neuropathy and pain after nerve injuries. Like in the other painful syndromes, medications may only incompletely help with this.
However, Ramachadran has described a novel and interesting therapy recently. By using mirrors that can give the appearance to the person suffering from phantom limb pain, the pain can be radically reduced. The visual feedback can modulate the other senses and alter the painful phantom limb sensation. The development of this therapy is still in its infancy and it remains to be seen whether similar techniques could lead to the treatment of other painful conditions. Other researchers have done similar experiments with virtual reality techniques.
•September 1, 2011 •
1. Never wear shoes with thin soles, open toes, slippers or sandals
2. Always wear socks. Thick white socks are best to absorb perspiration, protect the feet, and show blood or drainage if a wound develops.
3. Avoid shoes with an upper made from stiff, synthetic material (canvas, vinyl, or plastic), or shoes with a lot of stitching, because this will not stretch to conform to your feet.
4. Choose laced shoes made from soft compliant material, with a firm sole and plenty of width and height in the toe box. People eligible for Medicare can get prescription shoes for very little cost once a year.
5. Inspect your feet three times a day including in between the toes. If your knees or hips are too stiff to allow you to see the soles of your feet, use a mirror. If your eyesight is poor, ask a friend, spouse, or family member to help.
6. Never walk barefoot, even in the house or bathroom. Frequently, diabetic people develop serious wounds in their feet from stepping on small objects in the house.
7. Moisturize your feet with lotion daily, but avoid getting lotion between the toes.
8. Do not pare calluses or trim thickened toenails yourself. Get professional help.
9. Have your feet checked periodically by a physician to evaluate nerve damage and the blood circulation. Diabetes can lead to peripheral artery disease (PAD) and neuropathy which can increase your chance of developing ulcers and hamper your ability to heal them.
10. See your doctor at the first sign of trouble, such as unexplained swelling, warmth, redness, discoloration, wounds, bleeding, or drainage.
Blood Clots (Part I, What are they??)
•September 8, 2011 •
· Thromboembolism is clotting within the venous circulation and is different than bruising or hematoma formation in which the blood clots outside of the blood vessels.
· Thromboembolism can lead to vein damage, which sometimes results in chronic leg swelling, discoloration, and skin fragility.
· Thromboembolism can be dangerous if large fragments of the clots circulate to the lungs where they can block blood flow to the lungs.
What are blood clots?
When doctors talk about blood clots, they are referring to a condition called venous thromboembolism (VTE). In VTE, clots have formed within the veins, the vessels that return blood from the extremities and other tissue to the heart and lungs. A bruise or hematoma is quite different. Bruising is commonly caused by a blow to the leg and many other forms of injury resulting in bleeding into the tissue from damaged and torn blood vessels. While this blood does eventually clot in the tissue, it is no longer in the circulation within the veins and is not dangerous like VTE is.
The most common type of VTE is deep venous thrombosis (DVT). DVT is when the blood gels within the vein usually totally occluding it. If this happens, there may be no visible sign or symptom and often no pain. There are so many veins that if one gets blocked often there will be still enough to drain the venous blood from the tissue. If the vein is large and important enough it can cause the leg to swell or hurt.
The clotting can be self-perpetuating because the platelets, the small cells within the blood that controls clotting, release proteins that encourage more blood to clot. The clot can begin in a small segment of vein and extend up the vein. The larger the segment of vein affected the more likely it is that the problem will become serious, even life-threatening.
The clotted veins that are involved in the DVT sometimes do re-canalize or redevelop a center through which blood can flow. However, this vessel is not normal because the vessel wall is damaged. Along the vessel wall are valves, flaps that encourage the blood to flow toward the heart. The clots damage the valves. When the valves become damaged, the pressure within the veins increases. As a consequence, the blood pools into stretched out veins. These veins become the dilated varicose veins. The increased pressure causes small bleeds that stain the skin a brown color. This is called venous stasis dermatitis.
Venous stasis dermatitis makes the skin very fragile and when it is injured, the swelling inhibits healing severely. Also, as a result of the increased pressure against the vein walls, more fluid flows out of the vein walls into the tissue causing swelling.
The most dangerous consequence of DVT is pulmonary embolus (PE). This happens when a blood clot breaks away and floats down the vein to the lung where it gets caught in the circulation there. This keeps the blood from getting to the oxygen within the lungs. If it is large enough can actually keep blood from getting to one or both lobes of the lungs. Shortness of breath or death can quickly result. The clot usually needs to be from a fairly large vein in order to have a significant effect on the lungs.
Figure. Illustration of Vein Function. In normal circumstances, the valves prevent blood from flowing backward toward the feet, decreasing pressure within the veins. The normal contraction of the muscles pushes the blood through the veins. Clots within the veins attach to vessel walls. Some can break away and float toward the lungs. After organization of the clot, a opening can reform within the vessel, however, the valves no longer function properly leading to varicose veins. This increase in the pressure causes the legs to swell and the vessels to bleed more frequently.
Blood Clots (Part II, Prevention and Treatment)
•September 11, 2011 •
- In many high risk surgeries, medication or other means should be employed to prevent venous thromboembolism or blood clots.
- In foot and ankle procedures, the incidence of blood clots is very low and from the limited information that we have, it is more difficult to identify people that are at risk for these problems.
DVT and VTE occur with increased frequency after surgery or trauma. No one knows exactly how often they occur, because various studies have found incidences ranging from a few percentages to 70% in people with various high-risk conditions.
Many things affect the probability that you will develop deep venous thrombosis. Clotting is thought to occur as a result of three factors, trauma, stasis or blood slugging, and the body’s particular tendency toward clotting. The location of the surgical or accidental trauma is one of the most significant factors in the development of a DVT. The closer to the torso that the surgery or trauma is, the more likely that dangerous deep venous thrombosis will occur. Stasis is the lack of flow of blood through the veins. The more that the blood pools, the easier it is to interact with the proteins within the vein walls that initiate clotting. Braces, casting and lack of movement after surgery or trauma promote clotting by reducing muscle activity, an important method of pumping blood back to the body.
Medications that thin the blood are routinely prescribed to prevent clotting after high risk operations such as hip or knee replacement. In foot and ankle surgery, the reported incidence is much lower (0.22%) and therefore blood-thinning medications after foot and ankle surgery are not recommended (reference). No relationship has been shown between DVT risk and age, weight, diabetes mellitus, history of previous DVT, or any other medical condition in foot and ankle surgery. These have been described as risk factors for DVT after high-risk surgery. The only risk factor for DVT in foot and ankle surgery is immobilization and restricted ambulation after the surgery, which increased the risk to 0.45%
Unfortunately, blood clots are difficult to detect without sophisticated tests. Common signs are unusual swelling and pain in the calves, but this is also common after surgery and trauma without blood clots. Most people that develop them have no unusual symptoms. Ultrasound tests can detect some blood clots when symptoms suggest it may be present. Bruising and redness around the wound, calf or ankle is not a sign of deep venous thrombosis, but it is a sign of bleeding and inflammation under the skin, which is almost always present after surgery and is not usually dangerous.
Depending on your risks, your doctor may recommend certain preventative treatment. Early ambulation to the extent that is possible and motion of the foot and ankle is nearly always a good idea. Mechanical devices that squeeze the foot or calf may also be ordered, but are usually only practical in the hospital. Foot pumping exercises are often recommended (figure).
In addition, certain medications, some taken by mouth and others injected, may be recommended. The oral medication, warfarin (Coumadin), must be monitored by regular laboratory tests to measure its effect on clotting. Aspirin is sometimes suggested, but there is controversy over whether it is effective for preventing the most dangerous types of VTE. Other injectable medications are sometimes prescribed including enoxaparin (Lovenox) and fondaparinux (Arixtra). These medications are typically given for three weeks for the prevention of blood clots after surgery, but the ideal length of time necessary is not known. These medications do have some risks including bleeding, increased wound problems, allergic reactions, and, rarely, more serious side effects including bleeding into the brain and clotting disorders. There may also be a considerable cost for the medication or the laboratory tests used to monitor the medication.
Figure. Calf pumps. Calf pumping exercises use the body’s musculature to express blood through the veins to avoid stasis. These exercises may help prevent blood clots in the leg after surgery or trauma and have been shown helpful during plane flights.
•September 18, 2011 •|
Install hand rails near door and stairways
- Pick up or remove clutter
- Remove loose rugs from floor. Use rugs with nonskid backing if you cannot avoid using rugs.
- Keep cordless phones within reach in case of fall.
- Replace slippery linoleum and tile floors with high friction surfaces.
- Vary colors and textures on floors to accentuate changes in floor level
- Arrange furniture to provide open pathways .
- Keep electrical and telephone cords away from pathways.
- Ensure adequate lighting in areas with uneven floors or steps.
- Avoid flimsy furniture, glass tabletops and sharp corners on furniture.
- Clean up wet and greasy surfaces.
- Install grab bars around tubs and toilets.
- Place nonskid in tubs and showers .
- Discipline pets to stop jumping on people
- Remind children to pick up toys.
- Install sturdy handrails and guardrails around porches.
- Fix broken and unlevel walkways.
- Get out and walk regularly. This has been shown to decrease falls in people prone to them.
- Use a walker if you have fallen more than twice in the last three months.
- Take Tai chi, pilates, or other aerobic or strengthening exercises or exercise classes.
What you should Know about Worker’s Compensation
•September 21, 2011
Recovering from a work related injury is similar to recovering from a non-work related injury. It takes patience, rest, and close attention to your doctor’s instructions. Here are many questions that you may have about how worker’s compensation can help.
What is a Compensated injury?
Briefly, it is an injury that occurred at work. Generally, this includes fractures, tendon and ligament injuries and tears, bruises, and sprains. Sometimes, other injuries can be classified as compensable under the Worker’s Compensation Laws of some states.It helps to have your injury carefully documented promptly, before you leave the scene of the accident if possible. This includes reporting the injury to your supervisor and noting any witnesses that were with you at the time of the injury. The work-related contribution to problems such as arthritis, tendonitis, and other overuse injuries such as stress fractures, carpal tunnel syndrome, and unexplained pain is difficult to separate from the stresses of life outside of work and are not always compensable problems. Likewise, other aches and pains such as joint pain in surrounding areas from gait and motions changes during recovery may not be compensable.
What is Worker’s Compensation?
Worker’s Compensation is insurance that your employer must carry to ensure that, while you are recovering from an injury, your medical bills are paid. In addition, it helps to defray the financial loss that sometimes comes from your inability to fully work at your job.
Does my doctor treat me differently because this is a work injury?
Your doctor should not treat you differently because this is a work injury. However, at every visit, you will need to receive a work status note even if you do not think that your employer demands this and even if you have since left your place of employment. You will be expected to return to work when it is safe, if your employer is able to accommodate your work restrictions. Your doctor may need special permission to get tests, prescribe therapy or operate, but these requirements are usually no different than that required by other forms of insurance.
I still hurt. Why doesn’t my doctor keep me off work?
It is not your doctor’s decision to keep you off work unless it is unsafe for you to return in any fashion. It is your doctor’s decision to determine your capacity to work and relate any specific restrictions or situations that may be unsafe for you. An inability to drive, frequent need for narcotics, sleepiness because of medications, pain, the need to keep a wound clean or need to elevate an extremity does not necessarily restrict you from all work, but should be mentioned on your work restriction. If there is a specific activity or situation that you feel may be unsafe for you at work, please let your doctor know.
Who is my Nurse Case Manager?
A Nurse Case Manager is a nurse or other trained medical professional that understands your injury and methods of treatment and coordinates your care. He or she is also working hard to help you get well. Sometimes he or she will accompany you to your doctor’s appointments and help interact with the care team and insurance company to make sure that your care is prompt and that you get to the right people. She has a lot of experience with problems like yours and often offers excellent advice and suggestions.
What is MMI?
MMI is Maximal Medical Improvement. It is the point in your recovery that your physical capabilities have plateaued or, for the most part, gotten as good as they are going to get. Hopefully, you have returned to your old job by now, but you may have significant limitations, continued pain or deformity. If this is the case, your doctor should discuss ways to further eliminate this. If nothing further is felt to be of benefit by you or your doctor, then your doctor will determine a PPI rating and assign permanent work restrictions. MMI does not mean that you will never have any further problems or develop arthritis.
What is a PPI rating?
PPI stands for Permanent Partial Impairment. It is a method of calculating the amount that your injury has affected your ability to function and work. It is currently determined through very specific criteria published in The AMA Guides to the Evaluation of Permanent Impairment,Sixth Edition (AMA Press, 2008). This 613-page book lists the impairment ratings of many limitations of capability including losses of motion, strength, changes in gait or walking, deformity, swelling and amputation. It does not really take into account pain, which is difficult measure. It is not a perfect way of determining impairment, but is generally well accepted and agreed upon by doctors, insurance companies, and employers.
What is an FCE?
An FCE is a Functional Capacity Evaluation. It is a series of tests designed to document and measure your ability to work. Your ability to perform many work-related tasks is assessed. Many of these measurements require equipment and time not available at your doctor’s office. It gives the doctor and insurance company an objective opinion of your remaining problems. It is not always necessary at the end of treatment.
What happens after I am released from care?
Usually, your doctor will give you permanent work restrictions if they are necessary. If the injury recurs under Indiana rules, you have two years to reopen the case. If the complaint is brought to the attention of worker’s compensation insurance after this time, your rights to treatment under workman’s compensation be reduced or expired.
Rules vary from state to state. If you have further questions, please ask your doctor or Nurse Case Manager. In Indiana, you can also contact:
Worker’s Compensation Board of Indiana
402 W. Washington St., RmW196
Indianapolis, In 46204
Another Resource is The Guide toIndiana Worker’s Compensation at http://www.docstoc.com/docs/7251622/A-GUIDE-TO-INDIANA-WORKERS-COMPENSATION