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Posts for tag: foot

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
February 10, 2015
Category: Uncategorized
Tags: foot   skin   lesions   Chattanooga foot tumor  

     There are many instances where a biopsy of skin, other soft tissue, or bone is indicated in the foot and ankle.  Today, we will discuss just two cases where a simple biopsy is indicated.  These include PIGMENTED LESIONS and  DERMATITIS (or rashes).  In the foot and ankle, these are the two most common reasons for doing a skin biopsy.  

    Pigmented lesions are often benign.  In fact, on the foot and ankle it is probably safe to say that MOST pigmented skin lesions are benign.  Even the most professionally  trained and experienced physician  cannot always determine whether something is BENIGN or MALIGNANT just by the way it looks.  Nevi, also known as "moles" are benign and very common, but some nevi can become malignant.  A malignant melanoma, typically the most dangerous malignant skin lesion seen on the lower extremity, can often look like a wart.  It doesn't  have to look "black" or "multi-colored" or "eroded" or "ulcerated."   Also, malignant lesions on the lower extremity ofen look different than they do on other parts of the body.  Thinking that "it is probably a mole" can be very risky.   Basal cell and squamous cell carcinomas can also occur on the foot, and while not as deadly as a melanoma, if left unchecked they can result in significant deformity and can metastasize, leading to death.  A suspicious lesion can be easily removed from the foot using either a biopsy punch (a small, disposable device) or with a shave technique.  Either of these can be done under LOCAL anesthesia, and usually in 5 to 10 minutes.  In most cases, stitches are not needed, especially if the involved area is small.   Although the vast majority of these come back benign, more and more malignant lesions are being seen in the foot and ankle.  Definitive diagnosis is crucial.  

    A skin rash or dermatitis can also be easily biopsied, and often involves using a very small biopsy punch (2 mm in many cases) with a small amount of local anesthetic (often only 1.0cc).  This is particularly useful in cases of "Athlete's foot" (a fungal infection of the skin) that does NOT improve with antifungal medication.  Many cases of suspected Athlete's foot are NOT fungal infections at all.  They often turn out to be contact dermatitis, eczematous dermatitis, psoriasis, or other skin problems that are not infectious.  No amount of antifungal or antibiotic medication will help a skin problem that is allergic in nature,  or due to somehing other than an infection.  A skin biopsy can save the time and money involved in trying one medication after another, seeing no improvement, only to realize that what looked like a fungus was not a fungus at all!  Some dermatopatology labs (BAKO Labs, for example, who we utilize for ALL of our pathology specimens) not only can make a definitive diagnosis using a very small piece of skin, but can make treatment recommendations based on the microscopic appearance of the specimen.  This is invaluable when a patient is suffering with an itching, blistering, or dry and scaly skin rash for which nothing that has been tried, over the counter or prescription has helped.  

    There are MANY more cases where biopsy of lower extremity conditions is necessary and very helpful.  These can include NERVE FIBER DENSITY studies, FINE NEEDLE ASPIRATION, BONE BIOPSY and many more.  If you, or someone you care about, has something on the foot, ankle, or lower leg that just "doesn't look right", it may be time to get it checked out.  Please call us with any questions regarding a foot or ankle problem that needs to be checked out .  It may be nothing, but it also may save your life!

 

Richard S. Eby,. DPM
423-622-2663

www.rebyfootcare.com

    

By contactus@rebyfootcare.com
December 07, 2014
Category: Nail Treatments
Tags: foot   heel   alternative   plantar fasciitis  

  Whether we are talking about PLANTAR FASCIITIS (the most common cause of heel pain) or RETROCALCANEAL SPUR with Achilles Tendonitis, there are MANY available treatments.  Traditonal treatments for heel pain, which are usually tried first, include stretching exercises, NSAIDs (oral anti-inflammatories), ice, heat, rest,  heel cups, heel lifts, shoe modifications, over the counter supports or insoles, custom orthotic devices, night splint/AFOs, topical pain creams and rubs, steroid injections, physical therapy, and of course if all else fails....surgery. 

Then...there are a number of "alternative" treatments.  Some of these are fairly common, while others are a little more unusual.  Today, we will give a general overview of these available alternatives, all of which are non-surgical, and will cover many of them in much more detail in later posts.  So, here they are, in no particular order:  SHOCKWAVE (low energy and high energy), PRP (Platelet Rich Plasma), PEMF (pulsed electromagnetic therapy), OZONE INJECTIONS,  PODIATHERM,  and LASER TREATMENT.  I am sure there are others, but for now we are talking of treatments that are NON-SURGICAL and/or NONINVASIVE  (the Podiatherm is an exception because it does involve making a small incision) treatments for heel pain. 

One could also include herbal medications and acupuncture, but since I have no experience in these treatments, I will not cover these,  and I am sure there are some others that are used in certain cases.  What most of these treatments have in common is that they have little or no known (serious) side effects,  are done for the soft tissue problem causing pain and not bone, are usually not covered under traditional health insurance plans, are not done by a large number of physicians, but in many cases they are more "natural" type treatments that can sometimes result in very good outcomes and in some cases can result in a "cure" more than , say, a cortisone type injection, which almost always "wears off" after a period of time. 

Additionally, most of these involve either increased oxygen to the tissues - either directly, as in the case of ozone, or indirectly, as with PRP or Shockwave, where there is an increase in inflammation and then increased bloodflow to the area.  The increased bloodflow also resulting in increased oxygen in the tissues.   The Podiatherm is again, a bit of an exception here, because it is used more for nerve pain (entrapment) in the heel, and primarily works by heating up the nerve and making the nerve non-functional and basically causes an area to become "numb."   On the next few posts, we will go a little deeper into these treatments.

 

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

By contactus@rebyfootcare.com
October 13, 2014
Category: Uncategorized
Tags: foot   surgery  

Foot Surgery

Foot surgery may be necessary for a variety of reasons, but it is normally reserved for cases in which less invasive procedures have failed to help with the problem. Cases in which surgery may be deemed necessary include, but are not limited to, surgically removing deformities of the foot (such as bone spurs and bunions), problems with arthritis that have caused severe bone issues within the foot, and reconstruction to attend to injuries caused by accidents and congenital malformation (such as club foot and flat feet). Foot surgery may be necessary for individuals of all ages.

If you find yourself in need of foot surgery, the reason why the surgery has been found to be necessary will dictate exactly what kind of surgery you need. If you have to have a growth, such as a bunion, removed, then you may undergo a bunionectomy. If your bones need to be realigned and fused together, then you may undergo a surgical fusion of the foot. If it is nerve pain and problems that you are enduring, then you may need to undergo surgery in which the tissue that surrounds the painful
nerve is surgically removed. Normally other, less serious treatments are first applied when a problem is discovered, but if those treatments are found to be ineffective, surgical techniques are considered and used.

Even though surgery of the foot is usually reserved as a last resort by most physicians, there are some ben- efits if you and your doctor choose to use surgery to fix the problem. The first is that the pain associated with the issue is normally relieved, which means that you can finally resume the activities your foot problem was preventing you from participating in. The second benefit is that, once you have the surgery completed, the problem is generally eliminated since it has finally been addressed.

History of podiatry has shown that foot surgery techniques continue to advance every year. Endoscopic surgery is just one of the many advancements that have been made in the field of foot surgery. As technology improves, foot surgical techniques will also continue to improve. Many procedures can now be completed using a very small incision and smaller, more refined instruments. Because of these better tools, surgeries are becoming less invasive, and recovery time has become a great deal shorter. Shorter recovery periods mean that you will be back on your feet in no time.