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      When one hears the word "BIOPSY", visions of cancer cannot be avoided.  One thinks of breast biopsy, for example, and it is hard not to think of cancer as a possible finding.  In the foot, biopsy can take many forms.  There is biopsy of skin, biopsy of deeper soft tissue, fine needle aspiration of cysts and other fluid-filled masses, and in some cases bone biopsy.  Today - we are going to talk about the biopsy of the SKIN and other skin-like structures, such as NAIL or NAIL BED TISSUE.  While biopsy of the skin of the foot is done to rule out potential malignancies, such as basal cell carcinoma, squamous cell carcinoma, and malignant melanoma, there are many other reasons to biopsy.  

     Skin biopsy of the foot can be done to find out why the skin is discolored and/or dry and scaly.  Fungal infections, such as Athlete's foot, are often misdiagnosed.  A red, itchy, and dry/scaly area on the foot is not always fungus!   While dry and scaly red skin on the bottom of the foot, and extending into the web spaces (area between the toes) is probably fungal, there are other causes.  Bacterial infections can infect this area also.  Allergic reactions to things touching the skin (contact dermatitis), atopic dermatitis, psoriasis, eczema, and other non-infectious skin problems are much more common than fungus when the top, or dorsal aspect of the foot is involved.  Parasitic infections, including scabies and creeping eruption (larva migrans) can also cause severe itching, redness, and changes in the skin that may make one think there is a fungus.  Antifungal medications will have NO EFFECT on such conditions.  Making things even more interesting, it is possible to have a fungal infection between the toes that gets SECONDARY INFECTION with bacteria..  In this case, a culture of the drainage, along with a biopsy and/or culture for fungus is very beneficial.  A WOOD'S LAMP or ultraviolet light examination can also help. Skin biopsies in cases of red/itchy/dry skin can save the patient time and money in that a definitive diagnosis is made and there is usually no need to keep switching medications from antifungals - to steroids (cortisone type creams) - to another steroid - to a mixed steroid and antifungal.  You know which medication to use as soon as the biopsy report comes back.

   Skin biopsy can also be done to determine the diagnosis of a skin "tumor" when it is not certain by visually examining it, or when conservative treatment does not work.  Warts, for example, are very common on the bottom of the foot (PLANTAR WARTS).  These are often treated with cryotherapy (freezing), chemical cauterization with acid, electrical cauterization (Hyfrecation) or with a laser.  None of these, however, gives a specimen for microscopic examination.  If a wart-like lesion does not respond to these treatments, or it comes back again and again, a biopsy is indicated.  In many cases, sutures are not needed, expecially if the lesion is small.  Other things can look like warts - such as an IPK (very deep corn), porkeratosis (blocked sweat duct causing a wart like lesion), and foreign bodies (a small splinter or piece of glass can feel much like a wart).  Biopsy of one of these lesions is very helpful in determining the course of treatment.  If a lesion is treated as a wart, for example, and it is actually an IPK or corn, the problem will keep coming back because it is not a problem within the skin.  Such lesions are due to PRESSURE, and can be caused by a bone spur, accessory or extra bone, prominent metatarsal bone, or even the way the foot functions.  People with excessive pronation or flat feet often get a deep corn or IPK beneath the 2nd metatarsal head.  I have seen MANY cases where these were treated as warts - with freezing, acid, surgical removal, even skin grafting, and continual recurrence,  If the lesion had been biopsied, the microscopic exam would have shown that the layer of skin that is thickened is NOT what is seen with a wart, and that all of these treatments are futile.  Using a custom orthotic device or arch support would help to eliminate the pressure, and possibly eliminate the lesion altogether!  

    Bleeding under the nail - often referred to as "Tennis toe" and properly called a SUBUNGUAL HEMATOMA is a very common condition.  This is seen in very active people such as runners, tennis players, and other athletes.  It is due to pressure and friction of the nail against the nail bed or skin under the nail.  On the other hand, it can also be seen on older adults on blood thinners such as Coumadin or even aspirin.  A single traumatic event, such as dropping something on the toe, can also cause hemorrhage under the nail and it gets trapped and cannot come out.  The problem is that while 99+% of these "dark areas under the nail" are BLOOD, it is also possible to get a melanoma under the nail.  Melanomas are very serious, highly malignant lesions, typically non-painful, and cannot always be differentiated from blood just by looking at it.  Doing a punch biopsy, to remove a portion of the nail and some of the nail bed beneath it, is an excellent way to tell if the problem is just blood or a potentially fatal melanoma.  Nail unit biopsy can also be done in cases of suspected nail fungus, where the thickening and discoloration of the nail is not responding to medication, laser treatment, or other conservative measures.  Trauma to the nail can result in thickening and discoloration, and if there is no fungus present, topical antifungakl medication, oral antifungal medication, and laser will not work.  The nail may have to be removed.   I have also seen patients with psoriatic nails.  Psoriasis can cause abnormal looking toenails, and while they will often have "pits" or little holes in the nail, sometimes the nails just look thick and discolored with debris under the nails.  Some patients don't even know they have psoriasis, and again the use of medications for fungus will not help them.  Laser treatment may have some benefit in these patients, but they certainly will not respond the same way that fungus nails respond to laser. 

    Once again, biopsy of the skin on the foot can be used to confirm or rule out the presence of a malignant condition.  It must be understood however, that there are many other reasons that a biopsy of that thickened, discolored, dry, or wet skin or nail may be needed.  While most dermatologists, and many podiatrists do perform skin biopsy on the foot, this is one diagnostic tool that is NOT done often enough!   When the diagnosis of a skin or nail problem is questionable, or the problem just is not responding the way it should be responding, ask your doctor to do a biopsy.  

      

   

PODIATRIC MEDICINE is not often considered an "Alternative" healthcare field.  Recent advances in the treatment of foot and ankle conditions, especially those that have arisen out of technological advancements, have given birth to a whole new host of treatment options that can not be considered surgical, and certainly don't fit the usual definition of "medicine."  These include such modalities as SHOCKWAVE TREATMENT,  COLD LASER TECHNOLOGY, CLASS FOUR LASER TREATMENT, OZONE THERAPY,    NUTRITIONAL THERAPY,  NAIL LASER TREATMENT, PRP (Platelet Rich Plasma), and the list goes on!  

I am very happy to announce the premier of LASER FOCUSED FOOTCARE!  This is a Podcast I have developed to inform patients, prospective patients, and other interested parties about the many available treatment alternatives for foot and ankle pathology.  About once a week, I will discuss traditional, as well as "alternative", treatments for foot and ankle conditions.  I call it Laser Focused Footcare since  I have a profound interest in LASER therapy for pain and inflammation, as well as nail and skin conditions affecting the lower extremities.  I am developing and refining protocols for treatment of peripheral neuropathy using a combination of Cold Laser Therapy, Class Four Laser Therapy, and Vitamin/nutritional support.  This is a very innovative approach, and is DRUG FREE.    I still feel there is a place for TRADITIONAL therapies - and often write prescriptions for Gabapentin for neuropathy, NSAIDS for arthritis, give STEROID INJECTIONS for heel pain, and do BUNION SURGERY - when indicated.  I believe the public needs to be AWARE of all treatment options, educated on those options, and then make an informed decision.  Please join me by becoming a subscriber - SIGN UP IS FREE, but you need an iTunes account.   Once again - find my Podcast under Alternative Health - LASER FOCUSED FOOTCARE by Dr. Richard Eby.   Thanks for taking a step in the right direction!

Richard S. Eby, DPM

7348 E. Brainerd Road

Chattanooga, TN.  37421

(423) 760-3115

www.rebyfootcare.com

www.laserfocusedfootcare.com

By contactus@rebyfootcare.com
June 15, 2015
Category: Uncategorized

     A TAILOR'S BUNION is a bump on the outside of the foot (just behind the little toe).  It is an enlargement (either a truly enlarged bone or a relative enlargment) of the head of the fifth metatarsal bone.  There are five metatarsal bones, one behind each toe.  The heads, or ends of these bones make up the "ball" of the foot.  A bunion is an enlargrment of the first metatarsal head, often accompanied by a turning or shifting of the big toe towards the smaller toes.  A TAILOR'S BUNION Is basically the reverse.  The fifth metatarsal head is enlarged, and the little toe often moves in toward the other toes.

     Tailor's Bunion deformity is also sometimes called a "bunionette" and may be an actual enlargement of the bone (where the head is larger on the outside) or a "relative enlargmenet."  This means the fifth metatarsal may not actually be bigger, it may just look bigger because the entire fifth metatarsal is deviated OR there may be a bend or splaying of the fifth metatarsal.  In other words, the bone may be normal at the base, near the center of the foot, but there may be a bend in the bone causing it to bow outwardly.  The name "Tailor's Bunion" is one case where the deformity is NOT named after a doctor, as many deformities or surgical procedures are named.  Instead, it is called a TAILOR'S Bunion, because years ago, people who tailored clothing sat barefoot in a crossed leg position.  This put pressure on the side of the little toe, causing it to push in, and causing back pressure on the fifth metatatarsal pushing it out.  

    Treatment for a tailor's bunion is usually surgical.  While no treatment may be needed if there is no pain, ulceration, or other associated deformity, in many cases there is pain over the "bump."  In mild cases, an ostectomy or removal of just the "bump" can be performed.  This is in those rare cases where the bone is actually enlarged and there is little or no deviation or bend in the bone.  In most cases, an osteotomy is needed.  Defined sometimes as a "surgical fracture", an osteotomy is when a cut is made in the bone, the head (containing the "bunion") is moved in (closer to the fourth metatarsal) and held in place with a pin, screw, or other form of fixation.  In very severe cases, where the entire fifth metatarsal is out of position, it may be necessary to make the bone cut at the base of the bone.  In older individuals, patients with diabetes and ulcerations that may not be candidate for an osteotomy, the entire fifth metatarsal head can be removed.  This is not advisable for young, healthy individuals, as the cosmetic result is often not as good, and it is possible to regrow the bone. 

      Conservative treatments for this condition are not often effective long-term, but can include padding, wider shoes, injections of steroid solutions into the soft tissue (bursa) which may be inflamed and painful, the use of oral anti-inflammatory medications, and orthotic devices (especially if pain is plantar or on the bottom of the foot rather than just the side).  

      Tailor's bunion deformity is a common condition.  The condition may or may not be painful, and treatment is usually dependent on the severity of the deformity and symptoms.

 

 

Richard S. Eby, DPM
EbyFootCare and Laser Center

7348 East Brainerd Road'

Chattanooga, TN.  37421

(423)-760-3115

www.rebyfootcare.com

By contactus@rebyfootcare.com
June 07, 2015
Category: Uncategorized

  Excessive PRONATION can be a problem for children as well as adults.  Pronation is a triplane motion of the foot.  This means that when standing up, the foot normally goes through a motion described as pronation, and it occurs in all 3 body planes.  The arch typically lowers, the front part of the foot turns out a little, and the heel tends to evert (or turn so that it rolls out from under the ankle).  All of this is NORMAL - to a degree!  In order for the foot to adjust to uneven surfaces when it hits the ground, the foot is supposed to PRONATE, and then STOP PRONATING, and then SUPINATE - or start going the other way.  The arch should raise, the heel go back under the ankle, and the front of the foot rotate IN to make it a rigid lever to help push the body forward.  No one is 100% normal, but many people pronate or flatten out the foot TOO much when they stand, and this leads to what is often called a FLAT FOOT.   In adults, excessive pronation can lead to heel pain (plantar fasciitis), bunions, hammertoes, arch strain, and a whole host of other secondary problems.  

   There are many adults who pronate or flatten out their feet too much when they walk.  This starts in childhood.  Babies typically have a bulge of fat in the arch of the foot making all of them look like they have flat feet.  As they mature, this fat in the arch area should reduce, and the young child's foot  should take on the appearance of an adult foot, only smaller.  Some children have what looks like a very flat foot WEIGHTBEARING AND NON-WEIGHTBEARING.  This means the foot looks flat whether they are sitting or standing.  This is known as a RIGID FLATFOOT DEFORMITY.  Other children look normal when sitting, but when they stand, the arch lowers, their heels turn out from under the ankle, and they turn the front of the foot out.  This is known as a FLEXIBLE FLATFOOT DEFORMITY.  Not every child with flat feet (also known as pes valgus or pes planus) needs treatment.  The degree of the deformity is important, how the child walks, and whether or not there is any pain are imporatant considerations. 

   Custom orthotic devices are usually the first line of treatment for symptomatic and/or painful flat feet in kids.  Not all kids will say they hurt.  Some will not want to participate in sports, get tired easily, or seem to just be lazy.  If they relate LEG pain, especially cramping at night after they have had a busy day of activity, they may be suffering from this problem.  When in doubt, the best bet is to get it checked out.  A Podiatrist can evaluate the child's lower extremities ( feet, legs, knees, and hips) to see what may be abnormal.  If a hip, leg, or knee problem is found, referral to a Pediatric Orthopedist may be indicated.  If the problem is with the foot or ankle primarily, a custom foot orthotic may solve the problem.  The earlier this is instituted, the better.  If this does NOT resolve the problem - and I have seen cases where it completely eliminated the problem on ONE foot, but with deformity and/or pain remaining on the other foot - it may be necessary to consider surgery.  Unlike in adults, particularly in the FLEXIBLE FLATFOOT, soft tissue procedures may correct the deformity without resorting to osseous or bone procedures (often called osteotomies or arthrodesis - where bones are cut and repositioned or fusions of joints performed).  The use of implantable devices - once called a STA-PEG procedure, where a plastic plug or peg was placed in the foot to act as an "internal orthotic" - can be done successfully in many children, as long as significant arthritic changes have not occurred and the patient is young enough for the device to limit pronation successfully.    Secondary procedures, such as Achilles tendon lengthenings may also be needed, but the goal is to avoid surgery whenever possible.  In very young children, where there is an internal or external rotational problem in the lower limb, casting can also be instituted to attempt to turn the foot either OUT or IN, and there are also devices that can help with this, if used carefully and judiciously, in children that are not walking yet.  

   Excessive pronation or FLAT FEET can be considered borderline, mild, moderate, or severe.  It takes a skilled practitioner to determine the degree of the deformity, the necessity of treatment  and type of treatment that is necessary not only to resolve any presenting symptoms, but to reduce the likelihood of further problems as the child matures.  There are many adults with severe flat feet and secondary arthritic changes in the feet and ankles where the problem could have been prevented by recognizing and treating the problem when the patient was a child.  

 

Richard S. Eby, DPM

Eby FootCare and Laser Center

www.rebyfootcare.com

(423) 760-3115

   Foot surgery is often not considered to be MAJOR my many people.  Some of it, can actually be classified as MINOR surgery - especially that involving toenails, warts, cysts, and other surgeries involving a small incision or no incision at all.  There are foot surgeries done under LOCAL ANESTHESIA only, surgery done under GENERAL ANESTHESIA, and that which is classified as LOCAL with SEDATION.  While surgery under General Anesthesia is usually peformed in a hospital or surgery center, that done under LOCAL ANESTHESIA, whether done with or without sedation, can often be done in the DOCTOR'S OFFICE (if adequately equipped) OR in a hospital OR in a surgery center.  In many cases, the patient can choose one location over the other, but in far too many cases, the choice of the surgery is up to the surgeon, and the patient has little or no say in the matter.  

    Hospitals are typically the most EXPENSIVE option, and although most hospitals are well equipped to deal with potential complications or emergencies that may arise during the surgery, the most dangerous and immediate complications have to do with ANESTHESIA.  At one time, patients were admitted to the hospital the day before surgery, and then often spent one or more nights in the hospital after surgery.  All of that changed, starting back in the 1980's, when managed care became the buzzword, and the cost of being in a hospital, especially inpatient, became exorbitant.

   Surgery centers are usually less expensive than a hospital.  They still allow the patient to spend some extra time there postoperatively, especially if the patient takes some time to recover from the anesthesia.  Again, local anesthesia can, and often is used, for foot surgery.  Local anesthesia with IV or oral sedation can also be used.  In some cases, general anesthesia can also be used.  Surgery centers, however, are not the "bargain" that they appeared to be when they started springing up in the 1980's and 1990's.  The cost of the OR itself, the anesthesia, pathology lab to examine whatever specimen(s) is removed, the radiology (x-rays often done PRE- and POST-OP), along with ALL of the supplies used are itemized, just like in the hospital....and they must be paid either by YOU or YOUR INSURANCE COMPANY!   The surgeon's fees get paid to the surgeon whether in the office, hospital, or outpatient surgery center.  On top of all of that, MEDICAL DEVICE MANUFACTURERS sell most of their devices to the surgery center or hospital, and they pass the cost along to the patient!   Implants, which in foot surgery include such things as bone plates and screws, staples, pins, wires, etc. vary WIDELY in cost.  A k-wire can often be used to hold a toe in position when a hammertoe surgery is performed, but medical device manufacturers have come up with "new and improved devices" to hold the toe in position.  While some of these are nice devices, and they make the surgery more challenging and  interesting for the doctor, and have some benefit in healing - in certain cases, the cost can vary from $4 or $5 for a single K-wire to $1800 and sometimes $2000 or more for a really modern state-of-the-art device that can be a nightmare to remove if it ever becomes necessary to remove it.  So - add up the anesthesia fees, the radiology fees, the use of the OR (based on how long the surgery takes), the more expensive fixation devices used, along with additional lab fees, etc. - and that hammertoe surgery, for which the doctor may get a few hundred dollars, now becomes several thousand dollars!  "But my insurance will cover it" you say.   Maybe - maybe not.  Or maybe they will cover THIS surgery, but when it comes time to renew your health insurance, the premium is much higher each month, OR - they no longer cover "this type of surgery."

    I have seen patients have SOFT TISSUE SURGERY - repair of a tendon in one case - under LOCAL with SEDATION - where the total cost, including the surgery, anesthesia, supplies, labwork, etc. was nearly $30,000 !   And in this particular case, the patient had NO insurance.  If he had that same surgery done in the office - the "fees" would have been paid for - or "absorbed"  by the doctor.  That type of surgery would have been less than $1500, in fact, possibly less than $1000.  But instead - he is paying the surgery center every month until his bill is paid off.   Now.....what if he had health insurance?   First off all, he probably would have had a DEDUCTIBLE.  He may have had to pay $3000 or $5000 or more before his insurance would pay anything.... and then maybe he would have an 80/20 plan.  That means insurance would pay 80% After the deductible, and he would pay 20%.   So....let's just say he had a $2000 deductible - actually pretty good nowadays - and his insurance paid 80% of the APPROVED amount.  Well they probably would not approve $30,000.  Let's say they approved $20,000.  He would have paid $2000 deductible PLUS 20% of the remaining $18,000....so that is $3600. So when all is said and done, he would have STILL Paid $5600 for a tendon repair.  The insurance would have paid $14,400.  But if he went to a foot specialist with an OR in the office, he would have paid UNDER $1500.  Yes - the insurance would have paid $0.  I can tell you that my fee for that procedure, done in office would have been no more than $800.  Maybe less.   Even if he went to a doctor that charged a fee for the use of the in-office OR and anesthesia, MAYBE it would have been $1600 or $1700.  

    Sometimes "NEW and IMPROVED" is better.  Often times it is not.  If you are having foot surgery done - ask where the surgery will be done.  If done in the office, the doctor can give you a pretty good idea of the cost, and for how much you will be responsible.  He or she can't really do that if it is done in the hospital or surgery center.  Ask if it can be done in the office, and if so, can you be sedated at all or is it just local anesthesia.  If you are "pushed" into having the surgery at a certain surgery center, you may want to find out why?   Does the doctor have "ownership" in that surgery center?   If so, you can be sure the amount of money he or she will make off of doing the surgery will be far less than what the surgery center will make, but wait...that means the doctor will get some of that money also.  And there is nothing wrong with that.   It is perfectly legal, and he or she has a right to that money.  That doctor has invested in that surgery center and has a right to be compensated.  But, YOU,  as a patient just need to know.  You have a right to decide where your surgery is done.   You have a right to know how much you are going to be responsible for financially, because in this day and age insurance will only cover so much.  The days of "my insurance will pay it all" are over!

 

Richard S. Eby, DPM
Eby FootCare and Laser Center

7348 East Brainerd Road

Chattanooga, TN.  37421

(423)760-3115

www.rebyfootcare.com