Whole Foot
Prylotherapy is the injection of various medicines into painful areas of the body in order to improve pain. Unfortunately, many of the explanations for why these medications should work are poorly grounded in medicine. Little scientific proof exist that they are helpful. Still, clinics and practitioners that practice this make promising claims and can apparently attract a number of patients.
One of the most common form of treatment is the injection of high concentration glucose (sugar) solutions into painful areas. The explanation for this treatment is that it “produces inflammation” or “increases the energy of the cells”. Glucose is essentially sugar. Common table sugar (sucrose) is a molecule of glucose joined to fructose (fruit sugar). It is a small molecule and disperses into the tissues rapidly. It may initially irritate the local nerves, but has no lasting effects on the tissue. It is likely that the glucose concentration returns to normal minutes after injection.
With no reasonable scientific mechanism for its effect and no clinical evidence or benefit, it is difficult to understand why so many people choose to undergo these treatments.
Platelet Rich Plasma is a medicine that is created from your blood. Essentially, the blood is take from a vein and placed in a centrifuge and spun quickly. This causes the parts of blood to sediment into various layers according to their weight. The heaviest layer is the red blood cells, the lightest is the (platelet poor) plasma, the watery part of the blood that contains only soluble proteins, dissolved salt, and water. The layer in between is called the platelet rich plasma (PRP). It contains the platelets and white blood cells.
Platelets are little packets of proteins. The proteins within the platelets are released when the blood vessel walls are damaged. These proteins make the blood clot and begin the tissue repair process. Some of these proteins are called growth factors. There are many of them and they all have a job to do, but even after thirty years of studying them, it is not at all clear what any one of them do.
The proteins that the Platelet Rich Plasma (PRP) contains vary greatly from person to person and between each of the many systems that are currently on the market. The results from studies looking at the PRP and many different problems including arthritis, painful ligament and tendon problems, and many forms of wound healing problems are mixed. Some very encouraging, while others showing little effect. As this form of treatment is commonly not covered by insurance and is somewhat expensive, it would be advisable to determine what your out-of-pocket costs will be. I consider this treatment to be unproven currently and, therefore, am unable to recommend it until further study is done.
In many ways, physical therapy is a combination of art and science. Like many parts of medicine, there are a lot of unanswered questions about what is helpful, what is harmful, and what just feels good. A good physical therapist can provide emotional support, encouragement, reassurance and be a resource for answering questions about many parts of treatment. A therapist that is familiar with foot problems and understands the foot and ankle physiology, and they are hard to find, can improve the quality and results of non-operative care.
Physical therapy can be the most expensive part of treatment of an injury or surgery in terms of out-of-pocket expense. Despite its expense, it is often prescribed with little thought and excessively. It is not always necessary to go to see a therapist on a several times a week basis, anymore than it is necessary to see a doctor or an athletic trainer several times a week. A therapist has a couple of things to offer. Modalities which include ultrasound, massage, phonopheresis and other things which the therapist does to you. These things make you feel better, but do little to help you heal. Balance training and proprioception. And instruct on exercise programs. A well trained therapist that understands the foot can be a real asset in recovery from foot injury and surgery. However, it is necessary to see them only while learning the exercise routine and periodically, to add new more advanced exercises, to make sure that the exercises continue to be done correctly and to make sure the the exercises are having the desired effect.
Alcohol and phenol are two chemicals that have been used in the treatment of Morton’s Neuroma. Ethanol, the chemical that makes you intoxicated when you drink wine, beer, or other liquors, is irritating to the nerves (meaning, painful to inject into tissue), does relatively little long term damage because it diffuses into the water fairly quickly. Phenol is relatively toxic to tissue. Tissue on which phenol has been applied quickly becomes gray and kills the tissue to a depth of 1-3 millimeters. When it is used to kill the root of a toenail, it should be neutralized with alcohol. This is, of course, impossible with phenol injections. Surprisingly, there are fairly few reported cases of nerve irritation with the use of phenol nerve ablation. There are also few good studies that show a positive effect with its use. I classify this treatment as experimental and possibly hazardous.
Many of my patients asking me after an injury, “should I put ice on it or heat on it?” Their concerns include enhancing healing, reducing swelling, and lessening pain. Neither of these really does anything but the last, decreasing pain. Neither ice nor heat will penetrate into your tissues to where the injury is. While the skin may become quite cold or hot, there is too much blood circulating into and out of the area to allow the temperature change much deep inside your tissue where most injuries are located. Both ice and heat stimulate specific nerves that reduce the ability of your brain to perceive pain. This can be explained through “the Gate Control Theory Of Pain”. While there is nothing wrong with using ice or heat, whichever feels better, it should not be expected to make you heal faster or decreased swelling.
Epsom salts have been used in baths soaks for decades. It contains almost pure magnesium sulfate. This is placed in a bath to make for salt concentration within the bath similar to that in your tissues. This keeps the bath from sucking water out of or putting water into your tissues, making them shrivel. While magnesium can be absorbed somewhat through the skin, a deficiency of magnesium is very uncommon. Unfortunately, Epsom salts are not a cure-all for foot pains or infections. A warm bath can often reduce pain, but the Epsom salts did not do much beyond this.
Cortisone (or steroid shots) shots and pills are commonly used to treat a variety of problems including osteoarthritis, various types of tendon, nerve, and ligament irritation, and joint inflammation. But what do steroid or cortisone shots really do? What benefits can we expect to get from cortisone shots?
First of all, corticoids are a set of hormones that the body for a number of reasons. Testosterone, estrogen, and progesterone, the sex steroids, are the ones that athletes use to gain muscle. They are not commonly injected by doctors. Glucocorticoids, the most common ones injected by doctors, control inflammation when the body is under stress. They encourage cells to produce proteins that stop inflammation and stop producing proteins that promote inflammation. They are very useful in making painful areas less painful. They also in many ways stop the normal repair process, and there have been a number of times when doctors have suspected that it may cause rupture of tendons and ligaments when it is placed around these structures.
It is not clear that steroid shots do much over the long run for painful foot problems. If you observe foot problems over time, many of them will get better without treatment. The apparent “cure” of steroid injections and oral steroid pills may be the ability of these pills to cover up the problem until it resolves on its own. For the most part though, if the problem is unable to repair itself on its own, it is unlikely that steroid shots or pills will make it go away forever. This does not make these medications unuseful, but they should be used with caution. If prolonged improvement of the problem is not seen, they should not be continued in the hope that the next injection will be enough to cure the problem. Used judiciously, they can help make a self-healing problem more comfortable until your body is able to heal it.
Weight-bearing restrictions are necessary in the recovery of many injuries and surgeries involving the leg. Adhering to these restrictions is necessary for optimal healing and recovery. In many instances, premature weightbearing can lead to delayed healing or situations in which the bones do not fully mend. Further surgery or continued pain can be the result. In order to limit weight on your foot, some walking assistive device will be necessary.
The most common and easiest to find is crutches. Crutches can be a very effective way of walking without weightbearing in fairly fit patients. Some find it difficult to master. If this is the case, training by a physicial therapist can be helpful. Obese patients or patients without adequate arm strength can have difficulty with this however. Mastering going up and down stairs can be difficult also, but is possible in a relatively fit person with proper training.
Walkers are also a common choice. The advantage of a walker is that it is stable with four points of contact with the floor versus two with the crutches. However, avoiding complete weightbearing with a walker can be difficult. Usually, this employs some aspect of hopping. This can be exhausting and dangerous for some. In some patients, especially those with limited feeling in the feet such as people with diabetes, it can lead to stress injuries which can severely damage the foot. Any swelling or pain in the uninjured foot should be discussed with your physician immediately. Some walkers have a bench to rest on or to place the knee on while walking and these can be very helpful.
Another option is the kneeling scooter. As with the other forms of ambulation, this one has advantages and disadvantages, but can be very helpful for some. The kneeling scooter is a four wheeled device with handlebars to steer with and a bench to place your knee on. The injured leg’s knee is placed on the bench and the well leg is used to propel yourself. Please do not do this too fast or turn the handlebars too abruptly as you are likely to loose your balance and turn the scooter over. It can also not be used if the injury is close to or above the knee level.
A final option is a wheelchair. The wheelchair sometimes viewed as a symbol of dependance. Besides, there is a certain amount of exercise involved in using the above devices. Doing this exercise often helps stay in condition, which will be useful when you finally begin to walk.
Examples of ambulatory assistive devices.
A. The roll-a-tor
B. The roll-a-bout
C. Another model of roll-a-bout
Many common foot problems can be solved by proper shoe wear selection. Despite the fact that many blame their shoes for the development of their problems, your foot problem is more likely to be due to a life of simple use, genetic factors, and deterioration of specific structures than poor shoes. Certainly, shoe wear selection is occasionally a significant factor in the development of hammertoes and bunions, but I have a number of patients with all types of foot complaints who have never worn fashionable shoes. That being said, there are a number of foot pains that can be improved by careful selection of shoes.
A major consideration when choosing shoes to fix a bunion or hammertoe deformity is the size and makeup of the upper of the shoe. A soft upper with plenty of room in the toe box is crucial to accommodate these deformities and avoid abrasion of the skin and rubbing of the tissue. Avoid synthetic materials such as vinyl or plastic that do not conform to the foot well and do not give. Avoid seams over areas of prominence such as along the bunion. Walk around in the shoes for a period. The best time to fit a shoe is in the evening when the foot will be maximally swollen.
People often complain that when they find shoes that fit the front of the foot that the shoe no longer fits the heel. The heel as a result tends to be loose and slide often coming off or irritating the heel. Adhesive pads are made will fill this area often solving the problem. They are often found in shoe or drug stores, but if you have difficulty locating them, they can be obtained from the Hapad Company (www.hapad.com, item HG).
Rocker-soled shoes can alleviate certain foot problems, especially those problems that involve overusing the front of the foot such as plantar fasciitis, midfoot arthritis, metatarsal pains, or stress fractures. These shoes have a stiff sole that avoids stress concentrations on the ball of the foot and the sole is contoured so as to avoid an awkward gait as a result of the stiffness. The shoes also encourage an upright posture that is helpful in unloading the front of the foot. The claims regarding toning and shaping the buttocks are however unsubstantiated. Several companies including Dansko, MBT, Skechers, Timberline, Finn Comfort, New Balance, and SAS now make these shoes. Not all shoes made by these companies are rocker soled however. They are often referred to as toners. These shoes are widely available including a limited selection at Kohl’s, as well as more extensive selections at the Walking Company, Goodman’s, Eckstein’s, and Stout’s.
Orthotics are also very helpful in problems where limiting motion in the arch area is necessary. Most studies do not show an improvement in satisfaction or comfort with custom devices in people with typical foot shapes when compare to a noncustom insert. Occasionally, however, someone with a flat or very high arch does better with a custom insert. Custom inserts also work better in people where modification of design is necessary to aid in a particular deformity. At IOC, we carry Lynco arch supports which work very well for most problems. They are a high quality off-the-shelf arch support that should last 6-12 months. The price at which we offer them is competitive with similar devices on the Internet. A slightly lower quality insert may be obtained at many drug stores. However, I recommend that you evaluate and look at the Lynco support so that you can select a similar type from the drug store as they carry many arch supports that are not in my opinion very helpful.
Pain is a sensation which is transmitted by your nerves and interpreted by your brain. Why do you feel pain? Its purpose is to force you to protect or stop using an injured body part or to withdraw from things around you that may hurt you. Although pain may seem cruel and unpleasant, it is meant to keep you out of trouble and hurting yourself. The process that your brain uses to interpret these signals is unbelievably complex and therefore we make models to help simplify them.
One of these was proposed by Melzack and Wall in 1962 called “The Gait Control Theory of Pain”. In it, these researchers suggest that the transmission of pain signals through your nerves is restricted and modified by gates in your spinal cord and brain. These gates will encourage or inhibit the transmission of pain signals to your brain. Specifically, modifying factors such as your emotional state and other sensory inputs will decrease your sensitivity to pain. Your body has many types of sensory nerves including nerves that sense pressure, light touch, cold, hot, rubbing, vibration, and sharp and dull pain. The dull pain nerves, called C-fibers, are the ones that give injuries that dull, aching quality that usually people find most troublesome.
This is why people that are in the midst of a disaster, such as war, may be unaware of the severity of their injuries until after the stressful episode. On the other hand, someone that is worried, depressed, or overly afraid of their pain, will experience more pain than typical.
We use this too our advantage in treatment of painful conditions without even knowing it. While there is nothing wrong with doing things to a pain to decrease it, it is important to understand that these things do not do much to help us heal faster or better. They just help us get through the recovery easier. These pain modifying techniques include the application of cold (ice, topical sprays), heat (heating pads, wax baths, ultrasound, linaments such as Ben-Gay and Icy-Hot), compression (such as wrapping the area in an ace wrap), and vibration (rubbing, massaging, or using a TENs unit).
So, the use of ice, heat, and massage may make injuries feel better, but it is not necessary to use them according to any schedule. There is little evidence that any of these things reduce swelling or promote healing. Use them when you need a way to get your mind off the pain and stop using them when you feel better.
The idea that there are good and bad shoes is common. Often people blame their foot pain and foot problems on their “bad” shoes or a lifetime of abuse of their feet. This is not entirely accurate.
Wearing shoes, any shoes, changes the way that you walk and the way that your feet move and react to the ground whether you’re walking or running or doing any other type of activity. While shoes may protect your feet from injury from objects on the ground, over the long run the protection that they give your feet may actually work against you and make your feet weaker and more prone to many types of injury. Some shoes such as very high heeled shoes or shoes that cramp the toes may have an additional bad effect, but for the most part most shoes are not “good” or “bad”, only good or bad for certain problems at certain times. Just like there are incidences when a cast can be beneficial instead of a shoe, but a cast is not always beneficial to feet.
Other times, people equate “good” shoes with expensive or new shoes, but in reality, there is very little relationship between them. In fact, there seems to be less incidence of running injuries in runners who have worn shoes versus those with new shoes. The use of shoes tailored to the perceived foot type also seems to increase foot injuries.
Overall, it is best to use shoes that fit the activity that you are doing. That doesn’t mean that you need shoes specific sport, but select shoes that attach to the feet appropriately and are not unstable for more active sports so that you don’t trip and are able to change directions quickly.
Our entire team is carefully trained to evaluate your feet and identify any problems or potential problems. If your feet hurt, we’ll find out why. And if you’re simply looking for more energy and better comfort we’ll learn what you need to make that happen.
Then, once we know all that, we’ll recommend solutions from our wide selection of shoes, arch supports and accessories that are customized for your feet and your concerns.
We’re pleased to have served Flower Mound and delighted to have made so many friends here. We take pride in our expertise and experience and in the stylish, beautifully crafted shoes we offer. But what matters most to owner Mike Carey, C. Ped and every member of our team is your comfort and satisfaction.
If you have specific foot questions, write to me. I will be answer your questions in a general sense.
Our entire team is carefully trained to evaluate your feet and identify any problems or potential problems. If your feet hurt, we’ll find out why. And if you’re simply looking for more energy and better comfort we’ll learn what you need to make that happen.
Then, once we know all that, we’ll recommend solutions from our wide selection of shoes, arch supports and accessories that are customized for your feet and your concerns.
We’re pleased to have served Flower Mound and delighted to have made so many friends here. We take pride in our expertise and experience and in the stylish, beautifully crafted shoes we offer. But what matters most to owner Mike Carey, C. Ped and every member of our team is your comfort and satisfaction.
If you have specific foot questions, write to me. I will be answer your questions in a general sense.
Our entire team is carefully trained to evaluate your feet and identify any problems or potential problems. If your feet hurt, we’ll find out why. And if you’re simply looking for more energy and better comfort we’ll learn what you need to make that happen.
Then, once we know all that, we’ll recommend solutions from our wide selection of shoes, arch supports and accessories that are customized for your feet and your concerns.
We’re pleased to have served Flower Mound and delighted to have made so many friends here. We take pride in our expertise and experience and in the stylish, beautifully crafted shoes we offer. But what matters most to owner Mike Carey, C. Ped and every member of our team is your comfort and satisfaction.
If you have specific foot questions, write to me. I will be answer your questions in a general sense.
Our entire team is carefully trained to evaluate your feet and identify any problems or potential problems. If your feet hurt, we’ll find out why. And if you’re simply looking for more energy and better comfort we’ll learn what you need to make that happen.
Then, once we know all that, we’ll recommend solutions from our wide selection of shoes, arch supports and accessories that are customized for your feet and your concerns.
We’re pleased to have served Flower Mound and delighted to have made so many friends here. We take pride in our expertise and experience and in the stylish, beautifully crafted shoes we offer. But what matters most to owner Mike Carey, C. Ped and every member of our team is your comfort and satisfaction.
If you have specific foot questions, write to me. I will be answer your questions in a general sense.
Our entire team is carefully trained to evaluate your feet and identify any problems or potential problems. If your feet hurt, we’ll find out why. And if you’re simply looking for more energy and better comfort we’ll learn what you need to make that happen.
Then, once we know all that, we’ll recommend solutions from our wide selection of shoes, arch supports and accessories that are customized for your feet and your concerns.
We’re pleased to have served Flower Mound and delighted to have made so many friends here. We take pride in our expertise and experience and in the stylish, beautifully crafted shoes we offer. But what matters most to owner Mike Carey, C. Ped and every member of our team is your comfort and satisfaction.
If you have specific foot questions, write to me. I will be answer your questions in a general sense.
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 nonselective 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 4 gm per day (8 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 |
| Nonselective Over-the-Counter | ||
| Aspirin | Bayer | Low |
| Ibuprofen | Motrin, Advil | Low |
| Naprosyn | Aleve | Low |
| Nonselective Prescription | ||
| Diclofenac | Voltaren | Mid |
| Etodolac | Lodine | High |
| Indomethacin | Indocin | Low |
| Nabumetone | Relafen | Mid |
| Sulindac | Clinoril | Mid |
| Peroxicam | Feldene | Mid |
| Selective Prescription | ||
| Celecoxib | Celebrex | High |
