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Posts for category: F.Y.I.

By contactus@rebyfootcare.com
March 08, 2015
Category: F.Y.I.
Tags: foot   numbness   burning  

   For many, peripheral neuropathy is a painful, nagging, debilitating, and even dangerous condition.  Periperal neuropathy refers to progressive and degenerative changes that take place in the hands and feet off a growing number of people.  The feet, and especially the toes and ball of the foot, are affected sooner and more severely than the fingers and hands.   The most common underlying cause of these nerve changes is from DIABETES.   There are many other causes, however, including the use of -statin (cholesterol  lowering) medications, chemotherapy agents, vitamin deficiency, alcohol abuse, exposure to toxic chemicals and heavy metals (including lead, mercury, and aresenic), and the list goes on and on.  Surprisingly, the second biggest cause of peripheral neuropathy is IDIOPATHIC, meaning no underlying cause can be identified.  This is often seen in otherwise healthy individuals who have family memebers that are diabetic, people often labeled "prediabetic" (who show signs and symptoms of diabetes years later), and others for whom no underlying abomality is seen.

    Symptoms of neuropathy include NUMBNESS, PINS and NEEDLES sensation, BURNING, SHARP PAINS,  LACK OF COLD AND HOT DISCRIMINATION, PARESTHESIAS (unusual feeling such as "crawling sensations" or feeling things that aren't really there).  All of these are classified as SENSORY neuropathy - meaning things that you feel and should not feel, or (more importantly) NOT feeling things that you should feel.  Many people with neuropathy develop slow healing and non-healing ulcerations and infections because of cuts, puncture wounds, pressure from poor fitting shoes, and other external agents.  They may have good circulation, and if diabetic, their blood sugar may be under good or even excellent control, but they may lose a toe, foot, or leg because of NOT feeling something they should feel.  I have seen many bone infections, known as osteomyelitis, that resulted in amputation of a toe (at best), to loss of a leg (much worse), to loss of life (eventually) because of waiting until it was TOO LATE to get treatment.  This is often simply because "it didn't hurt" and the patient down-played the importance of that cut or ulceration until a spouse or other family member noticed blood, or drainage, or a bad odor.  Before it ever got that far, the "normal" non-neuropathic patient would have been in so much pain, they could not sleep at night, walk, or do anything other than "stop the pain!"

   There is no "cure" for neuropathy, but there are treatment options.  Often, a simple biopsy, known as an ENFD (Epidermal Nerve Fiber Density test) can be done to determine how much of the neuropathy is from the small (micrsocopic) nerve fibers.  A piece of skin 3mm in diameter is taken from just above the ankle, sent to a lab, and stained.  The number of nerve fibers per millimeter of skin is calculated, and this can give the treating physician valuable information in guiding treatment.  Nerve conduction studies or EMGs can also be done if the degree of large fiber neuropathy is to be determined.  Various drugs can be used for the PAIN of neuropathy.  These include over the counter pain relievers and anti-inflammatories such as tylenol, Aleve, or Advil.  Prescription drugs such as Neurontin (Gabapentin), Lyrica, and Cymbalta can also be used, and are often more effective for those with a moderate to moderately severe degree of neuropathy.  The bad thing is that all of these drugs can have side effects.  Many of them are dose-specific (Gabapentin for example has few side effects in low doses, but can cause memory loss, dizziness, and more in high doses).  Then...there are the narcotic drugs... best for those with SEVERE Neuropathy, because they are habit forming/addictive and have a whole host of possible side effects.  Constipation, respiratory depression, and much more is associated with prolonged narcotic use. 

   Safer, alternative treatments for peripheral neuropathy are becoming more common.  VITAMIN therapy is very helpful in many cases.  Alpha Lipoic Acid is one that I have found to be very useful.  It takes some time for this to help, but unlike many of the Rx. medications, this often reduces the numbness.   The "feeling" that has been lost in the foot or toes often returns.   I have found that many people using a combination of low dose gabapentin (for mild nocturnal pain), along with 600mg of alpa lipoic acid three times daily, can often keep their pain level low, and after 2-3 months see much of their "lost sensation" returning.  Benfotiamine is another vitamin that is often used successfully in many patients with neuorpathy.  A Thiamine blood level can be determined by a local lab, and if Thiamine is low, the use of Benfotiamine almost always helps.   A prescription "medical food" (classified that way by the FDA because it isn't a drug, but isn't really a vitamin either) known as Metanx is helpful also, especially in those where an ENFD is done and the nerve count is only mildly to moderately abnormal.  This actually will REGROW nerve endings in many people. 

   In my office, we are seeing great results also with LASER therapy for neuropathy.  This is a non-invasive therapy where a focused light beam is directed to the larger nerves in the feet, ankles, and sometimes lower legs, which can bring more circulation into the area, reduce inflammation, and actually heal damaged tissues at a cellular level.  The patient comes into the office for about 10 to 15 visits, usually spaced a few days apart, and receives treatments of each foot/ankle/leg for  10 to 15 minutes.  There are no side effects, and we have found that either a COLD (Class III) or HOT (Class IV) laser can be used for this condition.  In some cases, we use more than one frequency and "pulse" the laser for best results.   The treatment is relatively new, not available in many areas of the country, and is NOT covered by insurance.  Not only does this result in significant PAIN RELIEF, but also brings sensation back to previously "numb" areas, reducing the chance of infection, ulceration, and eventual amputation.  Of couse, this treatment can be combined with OTHER therapy - such as nutritional and vitamin therapy, for the best results. 

    As we see growing numbers of diabetics in the United States, and those individuals live longer because of better blood sugar control, successful treatment of related kidney and heart disease, there is bound to be MORE cases of peripheral neuropathy.  When we also take into account the cases of IDIOPATHIC neuropathy and those who have been successfully treated for cancer with chemotherapy and radiation, there is no question that neuropathy is going to be a problem for a lot more people.  Adequately evaluating and treating this condition becomes more and more important, so that people can lead happy, healthy, and active lives. 

 

Dr. Richard S. Eby

(423) 622-2663

www.rebyfootcare.com

By contactus@rebyfootcare.com
January 09, 2015
Category: F.Y.I.

Sclerosing Injections are a series of injections often used to treat a painful Morton's Neuroma in the foot.  A Morton's Neuroma is a nerve inflammation or neuritis that occurs when a nerve on the bottom of the foot, usually between the third and fourth toes, becomes compressed or otherwise irritated and enlarges.  It is NOT a tumor, despite the name given to it many years ago by Dr. Morton.  Pain and numbness starting in the ball of the foot and radiating into the toes is a common symptom, and it often becomes worse as the nerve becomes more inflamed or enlarged.  There are several ways to treat neuromas, with surgery being done less and less often.

 Steroid (cortisone) injecions and orthotic devices are probably used in the majority of cases first, especially if padding and changes in shoes do not help.  Unlike steroid injections which are given to shrink the nerve, often temporarily, sclerosing injections are given to cause a chemical neurolysis of the nerve, basically making the nerve no longer work.  While nothing is successful 100% if the time, a series of sclerosing injections, often between 3 and 7 of them spaced 10 to 14 days apart, is often very helpful in reducing and often eliminating the pain, numbness, burning, and tingling of a neuroma.

  Typically, a very small amount of the medication, often less than 1.0cc, is infiltrated directly into or on the nerve.  It is helpful to use ULTRASONIC GUIDANCE for this treatment to be sure the medication is right at or in the nerve.  With steroid injections, a larger amount of fluid is injected near the nerve, so that the medication "bathes" the nerve.  It is more important with a sclerosing injection to give the medication right at or behind the bifurcation (the y-shaped area where the nerve splits into two branches). 

A very small needle can be used for this, usually smaller than that used for a steroid injection, as long acting steroid medications are "thicker" and are not easily administered through a very thin needle.  The procedure takes only a few minutes, and the patient is helpful in communicating with the doctor when she feels the doctor is "getting close to the nerve."  Sharp, electrical shock type pains, which are relatively brief, will tell the patient the needle is very close to the nerve.  The medication is given in that spot, and then the procedure is over.

  The sclerosing mixture used is often a mixture of absolute alcohol, Marcaine (a long acting anesthetic), and epinephrine.  In the U.S., it is common to use a 4% solution, but in europe, where the procedure has been done for a much longer period of time, high concentrations of the medication are used.  This increases the effectiveness, and may reduce the number of injections needed, but it does carry some risk of "burning" the skin.  I, personally, have found that a 10% mixture works well in a majority of cases, and have had no untoward effects with that strength.  I have heard of mixtures as high as 20% being used in Europe, with a high success rate, but also a sometimes unacceptable rate of side effects.  In any case, the sclerosing injections are usually given every 10-14 days until the patient sees a nearly complete resolution of symptoms.  I have found, in my practice, that anywhere from 3 to 7 are needed.  We usually then evaluate the patient several weeks to a few months later, to be sure there is no recurrence.

Dr. Richard S. Eby

(423) 622-2663

By contactus@rebyfootcare.com
December 21, 2014
Category: F.Y.I.
Tags: heel   orthotics  

CUSTOM FOOT ORTHOTIC devices can be used for many deformities and conditions that affect the foot and ankle.  Plantar Fasciitis or Heel Spur Syndrome, however, is one of the primary indications for using custom foot orthotic devices, and for any arch support or insole.  Plantar fasciitis is a totally MECHANICAL problem, where the arch is under stress and strain because of a tight plantar fascia.

  The plantar fascia is the thick, avascular (no real blood supply - hence it looks white and not red like muscle tissue) ligament that starts on the bottom of the heel, runs up through the arch into the ball of the foot, and ends as it sends off small slips into the toes.  There are many reasons that people suffer with heel and arch pain that comes from a tight or strained plantar fascia.  Long periods of standing on hard surfaces, excessive weight, sports activities, and functional/structural foot deformities such as flat feet and high arch feet are just a few of the things tha can cause the fascia to pull harder and result in the condition known as plantar fasciitis. 

A mechanical or functional cure often works as well as, if not beter, than other treatments such as injections, oral NSAIDs, physical therapy. or surgery.  Unlike a injection, which is often very beneficial for immediate or almost immediate short term reief, orthotic devices take time.  A cast or 3D image of the foot is made, almost always for BOTH FEET, even if one foot does not hurt.  This can be done using a plaster slipper cast of both feet, a fiberglass sock cast of both feet, or an electronic scan, where the patient stands and/or walks over a force plate connected to a computer which records high and low pressures when the bottom of the foot hits the ground.  A lab then takes the scan or cast and creates a device (often semi-firm to firm for heel and arch problems) which creates a more ideal position and weighbearing pattern for the foot. 

These can be full length (all the way to the tips of the toes), sulcus length (ending at the base of the toes), or 3/4 length (which ends near the ball of the foot, fits easier in the shoe, and is usually adequate if no toe or metaarsal head problems need to be accounted for).  The devices are then sent back to the doctor who ordered them, and they ae then dispensed to the patients.  Just like with contact lenses, there is usually a breaking-in period.  This may be a matter of a few days, or as long as a few weeks, and often depends on the age of the patient (children are usualy quicker to adjust), the hardness or rigidity of the device, any other lower extremity problems (like knee or hip problems) and how much correction is needed in the devices.  

Follow-ups and adjustments are sometmes needed, but in many cases, improvement is seen fairly quickly.  After wearing the devices for awhile, there is a tendency for many people to forget about their heel problem after a few months, and to eventually go without the devices.  There are many cases where patients "lose" the devices, and two or three years later, come back saying that the pain was gone for over a year, so they tought they "didn't need them anymore."  After 6 to 12 months without them, the pain came back.  If you have pain in either or both heels or arches, and other treatments have given only temporary or partial relief, consider orthotic devices.   They may just be the best investment in YOU that you have ever made! 

 

Richard S. Eby, DPM

(423) 622-2663

By contactus@rebyfootcare.com
December 15, 2014
Category: F.Y.I.

HEEL INJECTIONS can be of more than one type.  For the purposes of this discussion, we will be talking about STEROID INJECTIONS for heel pain, primarily for Plantar Fasciitis.  Injection  into the bottom of the heel for plantar fasciitis, or what has often been called "heel spur syndrome" is very common, and in many cases, very effective. 

Note that I said IN MANY CASES.  The term Plantar Fasciitis implies that there is inflammation within the ligament we know as the plantar fascia, and that is what causes the pain that heel pain sufferers are very familiar with - pain on arising first thing in the morning, pain that gets worse after walking following a period of rest, pain that is often worse barefoot or when wearing flat or non-supportive shoes.  But the pain we are talking about is due to a MECHANICAL cause, and NOT an inflammatory cause.  There is usually no swelling, redness, or other signs of inflammation in the heel or arch. 

There may be thickening or degeneration of the plantar fascia, which can be seen on Ultrasonic imaging of the foot, and can be very helpful.  But there is NO real inflammation.  Microscopic studies of the "diseased" or thickened plantar fascia that was removed surgically have consistently showed NO signs of inflammation.  So why do non-steroidal medications taken by mouth and steroid injections usually help, at least to a degree?  They have PAIN relieving properties as well as anti-inflammatory properties. 

It has also been showed that the act of "needling" the fascia can help in reducing pain.  It is possible that the act of putting a needle into the fascia can cause it to repair itself, at least to a degree.  Injections can be given into the heel under ULTRASONIC GUIDANCE, making the delivery of the steroid medication more precise.  While steroid injections are not without their risks, the bottom of the heel, with its typically thick pad of fat, is a much safer area to inject than thin skinned areas such as the sides and tips of the toes, or especially the BACK of the heel, where the Achilles Tendon can be damaged or even rupture, especially with repeated injections. 

It is possible to rupture the plantar fascia with steroid injections, but this is fairly uncommon, and since the plantar fascia is not a tendon or muscle, and simply a ligament, there is no loss of function if that should occur.  Surgery for plantar fasciitis, which should only be considered when conservative treatment fails, involves a deliberate cutting of the tight plantar fascia.   Steroid injections should NOT be given haphazardly or repeatedly if no benefit is being obtained with them, but in may cases, corticoteroid injections can give significant relief to the plantar heel pain sufferer, and may eliminate the need for invasive surgery. 

 

Richard S. Eby, DPM

(423) 622-2663

By contactus@rebyfootcare.com
November 23, 2014
Category: F.Y.I.
Tags: ankle   foot   plantar fasciitis  

Plantar Fasciitis is one of the most common conditions that affects the foot.  Years ago, this was referred to as HEEL SPUR SYNDROME because a bone spur on the bottom of the heel is often seen with the condition we now refer to as plantar fasciitis.  Actually, the presence or absence of a "spur" on the bottom of the heel has little, if anything, to do with the pain one gets with this condition.

 Plantar fasciitis is a mechanical thightening that occurs, usually just in front of the bottom of the heel bone, at the attachment of the plantar fascia.  The plantar fascia is a thick, tough, ligamentous band that runs from the heel, through the arch and ends near the ball of the foot at the toes.  A number of things can cause this to become tight and cause pain, often when first putting pressure on the heel in the morning or after a period of rest.  BUT, the idea of INFLAMMATION in this ligament is simply not the case.

 While oral anti-inflammatory agents (also known as NSAIDs) such as Ibuprofen, Naproxen, and many others)  and steroid injections often reduce, and in some cases eliminate the pain, WHERE IS THE INFLAMMATION?????   Rarely does one see swelling, redness, or heat in the area on the bottom of the heel.  In fact, surgical removal of portions of the fascia, when sent for microscopic examination rarely show signs of inflammation.

 For this reason, there is a movement to change the name of this dreaded condition to PLANTAR FASCIOSIS or even PLANTAR FASCIOPATHY.  This name implies deformity or diseased areas within the plantar fascis rather than actual inflammation.  There are also cases where removing small parts of the plantar fascia that appear abnormal on ultrasound exams of the fascia, and "needling" the remaining fascia, or injecting stem cells and/or platelets that are separated from the patient's own blood can cause the body to "heal itself."

 Shockwave therapy, something we will go into more detail on later, can also cause the fascia to "heal" on its own.  These points seem to suggest that INCREASING the inflammation in and around the ligament is actually a good thing, and can lead to reduced pain, and in some cases, complete resolution of symptoms.  No matter what one calls it, plantar fascitiis is a condition that affects many people, and can be treated in a variety of ways.  

Dr. Richard S. Eby   

423-622-2663